GI · Full case

Constipation

NICE NG12 / TA211 / TA345

Rome IV≥2 features for ≥3 months: functional constipation criteria

BSS 1–2Bristol Stool Scale: hard/lumpy — constipation range; target BSS 3–5

FibreGradual, individualised increase in soluble fibre — no universal daily target for constipation (BDA 2025)

~1.5 LDaily fluid as a general guide, not a target for everyone — individualise in heart failure, CKD and frailty

4 weeksAdequate laxative trial before escalation decision

FITRectal bleeding or change in bowel habit → suspected cancer pathway referral if FIT ≥10 µg Hb/g (NG12)

Macrogol 1stPreferred first-line osmotic in UK practice — not lactulose

No AXRAbdominal X-ray not indicated for typical constipation

📋 Clinical Stem — Constipation / Change in Bowel Habit

A patient presents with difficulty opening their bowels, infrequent or hard stools, or a sensation of incomplete evacuation, with or without associated symptoms.

"Mrs Linda Patel is a 52-year-old office administrator presenting with a 6-month history of constipation — opening her bowels every 3–4 days with hard, lumpy stools requiring significant straining. No rectal bleeding, no weight loss, no family history of bowel cancer. She drinks mainly coffee with little water and takes codeine for back pain. She feels bloated and uncomfortable, and has been embarrassed to raise this until now."

Three decisions drive the constipation consultation: (1) Is there a red flag requiring urgent investigation? (2) Is there a reversible drug or secondary cause? (3) Is this functional constipation — if so, manage with lifestyle + laxatives stepwise. In SCA, red flag screening and the drug history are the two most clinically important elements.

Scenario A — Functional constipation Middle-aged adult, no red flags, lifestyle or drug cause. Lifestyle → ispaghula (bulk-forming) → osmotic (often macrogol) ± stimulant. Rome IV criteria met.

Scenario B — Opioid-induced constipation (OIC) Regular opioids (codeine, morphine). Macrogol + bisacodyl from day 1 of opioid therapy. Naloxegol if refractory.

Scenario C — Red flags (suspected cancer pathway) Rectal bleeding, weight loss, IDA or a change in bowel habit → FIT; colorectal suspected cancer pathway referral if ≥10 µg Hb/g, or a rectal mass. Do not manage as functional.

Scenario D — Faecal impaction Severe constipation, hard mass on DRE. High-dose macrogol disimpaction regimen (8 sachets/day × 3 days). Maintain on regular laxative after disimpaction.

Scenario E — IBS with constipation (IBS-C) Abdominal pain relieved by defaecation, bloating, altered habit. Rome IV IBS criteria. Low-FODMAP + targeted pharmacotherapy; linaclotide if first-line fails (≥12 months).

Steps:

Step 1

History Taking — Open Question First · Red Flags · Drug History · ICE · Psychosocial Context

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The constipation history has one overriding priority: exclude colorectal cancer before managing as functional. The bowel history must screen for red flags (rectal bleeding, weight loss, age), characterise the stool pattern, identify reversible drug causes (opioids most common), and assess for secondary causes (hypothyroidism, hypercalcaemia). ICE in constipation often uncovers significant embarrassment and cancer fear that must be addressed directly.

🎓 Consultation opener — normalise the topic first

"These things can be really awkward to talk about, and I want you to know this is one of the most common things I see. You've absolutely done the right thing bringing it up. Tell me in your own words what's been happening."

Acknowledging the embarrassment before asking any clinical questions creates a safe consultation space, dramatically improves information quality, and gains an empathy mark in the Relating to Others domain.

1A — Key targeted questions: what changes management

Question	Why it matters clinically	Changes what?
🟢 OPEN — always start here"Tell me in your own words what's been happening — when did things change, and how is it affecting you?"	Establishes duration, pattern, and functional impact. Duration is critical — a new change in bowel habit over weeks is a red flag (FIT, NICE NG12); long-standing constipation since childhood is a different scenario entirely.	DDxUrgency
Rectal bleeding"Have you noticed any blood — in the toilet, on the paper, or mixed in with the stool?"	The single most important red flag question. Blood mixed in stool (dark, altered) is more sinister than blood on paper (likely haemorrhoids/fissure). Rectal bleeding with abdominal pain or weight loss under 50, or any rectal bleeding at 50+, needs FIT under NICE NG12 — and a suspected cancer pathway referral if ≥10 µg Hb/g — regardless of presumed cause.Never attribute rectal bleeding to haemorrhoids without investigation — this is a common cause of delayed colorectal cancer diagnosis.	Suspected cancer pathway referralEmergency
Unintentional weight loss"Have you lost any weight recently without trying — over the past 3–6 months?"	NICE NG12: a change in bowel habit at any age, or weight loss with abdominal pain at 40+, warrants FIT; suspected cancer pathway referral if ≥10 µg Hb/g. Also consider malignancy causing partial bowel obstruction, hypothyroidism, depression, systemic illness.Quantify: "how much, over what period?" — unintentional loss >5% body weight in 6 months is clinically significant.	Suspected cancer pathway referralDDx
Medications — especially opioids, iron, CCBs"What medications are you taking, including painkillers, iron tablets, antidepressants, blood pressure tablets, or antacids?"	Drug causes are the most common and most reversible cause. Key offenders: opioids (most potent — bind enteric mu-receptors, completely suppress peristalsis), iron supplements, calcium channel blockers (verapamil worst), tricyclics, anticholinergics, aluminium antacids.Opioid-induced constipation (OIC) does not resolve with dietary fibre and fluids alone — it requires macrogol + stimulant laxative from day one of opioid therapy.	DDxManagement
Stool pattern — frequency, consistency (BSS)"How often do you open your bowels? Are the stools hard and lumpy? Do you strain a lot?"	Normal: 3×/day to 3×/week. The change from the patient's own baseline matters as much as absolute frequency. BSS 1–2 = constipation; BSS 3–5 = normal target on treatment. Showing the patient the BSS removes embarrassment from the description and provides standardised clinical documentation.	DDxManagement
Abdominal pain and defaecation relationship"Do you get abdominal pain — and does it come before you go to the toilet, and get better afterwards?"	Pain relieved by defaecation is a key Rome IV feature of IBS — distinguishes IBS-C (abdominal pain criterion required) from functional constipation (no dominant pain). IBS-C has specific pharmacotherapy (linaclotide, low-FODMAP) that differs from simple functional constipation.	DDxManagement
Fluid intake and diet"How much water do you drink? And what does your diet look like — much fruit, vegetables, or wholegrain food?"	Individualise: a gradual increase in soluble fibre where appropriate (no universal daily target) and adequate fluid (around 1.5 L/day as a guide, not for those on fluid restriction). Critical: increasing fibre without adequate fluid worsens constipation (fibre absorbs water). Fluid must be addressed before fibre.Kiwi fruit: RCT evidence for constipation relief — 2 kiwis/day. Linseeds 1 tbsp/day: cheap and effective. Oats, lentils, beans: affordable high-fibre foods.	Management
Toilet habits — holding, posture, routine"When you get the urge to go, do you respond to it straight away? And do you have easy access to the toilet at work?"	Suppressing the defaecation urge raises the threshold for the next urge — worsening constipation progressively. Restricted toilet access at work (shame, inconvenience) is a common and underrecognised maintaining cause. A footstool (knees above hips) is a reasonable low-risk measure that may ease evacuation.	Management
Secondary causes — thyroid, diabetes, neurological"Have you been diagnosed with an underactive thyroid, diabetes, or any neurological condition?"	Hypothyroidism (reduced gut motility), hypercalcaemia (smooth muscle depression), diabetic autonomic neuropathy, Parkinson's disease, MS — each requires treatment of the primary condition rather than just escalating laxatives.Hypothyroidism is the most commonly missed secondary cause — check TFTs in any patient with constipation plus fatigue, cold intolerance, weight gain, or hair loss.	DDxInvestigations
Neurological symptoms with bowel change"Have you noticed any weakness or numbness in your legs or difficulty with your bladder — alongside the bowel change?"	New bowel dysfunction with back pain and lower limb neurological signs = cauda equina syndrome until proven otherwise — a neurosurgical emergency. This presentation masquerades as constipation; "constipation" in this context is neurological bowel dysfunction, not functional.	Emergency

1B — Red flags: must not miss

🚨

Red Flags

Red flag	Why dangerous	Action
Rectal bleeding (with pain or weight loss under 50; any at 50+)	NICE NG12: colorectal cancer until proven otherwise — do not assume haemorrhoids without investigation in this age group	FIT; suspected cancer pathway referral if ≥10 µg Hb/g
Change in bowel habit (any age), or weight loss + abdominal pain at 40+	NICE NG12 FIT criterion (suspected cancer pathway referral if FIT ≥10 µg Hb/g) — malignancy, lymphoma, malabsorption, systemic illness	FIT; suspected cancer pathway referral if ≥10 µg Hb/g
Absolute constipation + no flatus + distension + vomiting	Large bowel obstruction — surgical emergency; perforation risk if laxatives given	999 / A&E
New bowel + bladder dysfunction + leg symptoms	Cauda equina syndrome — neurosurgical emergency; MRI spine within hours	999
Iron-deficiency anaemia (any age)	NICE NG12: right-sided colonic malignancy commonly presents with IDA only; FIT under NG12, and upper and lower GI investigation (BSG 2021)	FIT; suspected cancer pathway referral if ≥10 µg Hb/g

1C — ICE: Ideas · Concerns · Expectations

💭 Ideas

"What's your own thinking about what might be causing this?"

Common models: "It's my diet"; "it's the codeine" (already knows — validates the explanation); "it might be something more serious." Establishing the model determines whether your explanation is needed or just confirming what they already know.

😟 Concerns

"Is there something you've been worried this might be — sometimes people worry about more serious causes?"

Cancer fear is almost always present in patients with new bowel symptoms who have a family history or personal health anxiety. If identified, it must be directly addressed with the specific red flag screen referenced: "I've specifically checked for bleeding and weight loss — those are absent, and the cause here is clearly the codeine."

🎯 Expectations

"What were you hoping we'd be able to do today — a prescription, reassurance, or a camera test?"

Some patients want a colonoscopy for reassurance. Others want a stronger laxative. Some want to understand why OTC preparations failed. Establishing the expectation before the management plan prevents the consultation ending with an unsatisfied patient who got something they did not want or did not get what they came for.

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"These things can be awkward to discuss — you've done absolutely the right thing raising it."

"Have you noticed any blood — in the toilet, on the paper, or in the stool itself?"

"Is there something you've been worried this might be?"

"What medications are you on — any painkillers? Codeine?"

Deductions (examiner flags)

Not asking about rectal bleeding — the single most important red flag in any bowel presentation
Not asking about drug causes — opioids and iron are extremely common causes; missing them prevents the simplest fix
Not acknowledging the embarrassment of the topic — closes the consultation environment
Cancer fear not explored in ICE — leaves patient anxious throughout; undermines management engagement

🔴 Red

No red flag screening. Drug history not taken. ICE absent. Embarrassment ignored. Jumps to laxative prescription.

🟠 Amber

Rectal bleeding asked but weight loss not screened. Drug history incomplete. ICE explored but cancer fear not specifically named.

🟢 Green

Embarrassment acknowledged at outset. Red flags fully screened (bleeding, weight loss, age). Drug history including opioids. ICE with cancer fear specifically named and addressed. Lifestyle factors assessed.

Step 2

Triage Engine — Emergency · suspected cancer pathway referral · Routine

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Triage decision: does this need suspected cancer pathway investigation, emergency management (obstruction/cauda equina), or routine primary care management? Missing a suspected cancer pathway referral indication by managing red flag symptoms as functional constipation is one of the most common causes of delayed colorectal cancer diagnosis.

🔴 Emergency / suspected cancer pathway referral

999 or Same-Day / suspected cancer pathway referral

Act now

Large bowel obstructionNo flatus + distension + vomiting → 999 surgical emergency; do not give laxatives
Cauda equina syndromeBowel/bladder change + leg symptoms → 999 emergency MRI; not functional constipation
FIT: bleeding, weight loss or bowel changeNICE NG12 → colorectal suspected cancer pathway referral if FIT ≥10 µg Hb/g; do not delay with laxative trial first
IDA at any ageFIT (NICE NG12) → suspected cancer pathway referral if ≥10 µg Hb/g; men and post-menopausal women also need upper and lower GI investigation (BSG 2021) + iron replacement
Palpable abdominal or rectal massRectal mass → suspected cancer pathway referral without FIT; abdominal mass → FIT plus urgent imaging (NICE NG12)

🟠 Urgent

Same-Day / Days

Days

Faecal impactionSevere pain, unable to open bowels >7 days, hard mass on DRE → macrogol disimpaction regimen; if no response 48h → phosphate enema
Suspected secondary cause (hypothyroidism, hypercalcaemia)New constipation + systemic symptoms → urgent TFTs + calcium before laxative treatment
Constipation in known malignancyOIC or tumour effect → specialist palliative care bowel regime; naloxegol if OIC

🟢 Routine

Primary Care Management

GP practice

Functional constipation (Rome IV, no red flags)Lifestyle → ispaghula → macrogol ± stimulant; review at 2–4 weeks
Drug-induced (opioids, iron, CCBs)Stop or switch drug; macrogol + bisacodyl for OIC from day 1; 4-week review
IBS-CLow-FODMAP diet; macrogol; linaclotide if failed 12 months first-line
Constipation in pregnancyIspaghula husk + lactulose; avoid bisacodyl 1st trimester

🎓 SCA Checkpoint — Step 2TasksGlobal Skills

Key phrases that score

"I'm not picking up any of the specific warning signs that would make me want to refer urgently — no blood, no weight loss, and a clear drug cause. However, I want you to know that if either of those things ever develop, please come back immediately."

Deductions

Prescribing laxatives without documented red flag screen — medico-legally risky
Not offering FIT for rectal bleeding, weight loss, IDA or a change in bowel habit
Treating obstruction as constipation — risk of perforation if laxatives given

🔴 Red

Laxatives prescribed without red flag screen documented. Suspected cancer pathway referral criteria missed. No safety-net for red flag development.

🟠 Amber

Red flags screened but suspected cancer pathway referral criteria not explicitly stated. Triage reasoning not communicated to patient.

🟢 Green

Red flags screened and documented. Routine pathway appropriate. Red flag development safety-net given specifically.

Step 3

Do I Need This Examination?

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Abdominal palpation and digital rectal examination (DRE) are the two most important examinations. DRE detects rectal masses, faecal impaction and anal fissure; offer it where it will change management (new, unexplained or refractory constipation, suspected impaction, bleeding, mass, neurological disease) — with explanation, explicit consent, and a chaperone. An empty rectum does not exclude proximal loading or slow transit.

Examination	Why it matters	Finding that changes management	Changes management?
Digital rectal examination (DRE)	Most important examination in constipation. Detects: rectal carcinoma (hard irregular mass), faecal impaction, anal fissure, rectal prolapse. Also assesses sphincter tone; PR alone cannot diagnose dyssynergia (needs specialist anorectal physiology).Offer with chaperone; explain clearly; check consent explicitly before proceeding. Document if patient declines.	Hard rectal mass → suspected cancer pathway referral (urgent colonoscopy). Hard stool → disimpaction regimen. Empty rectum does not exclude loading or slow transit. Suspected defaecatory dysfunction → refer for anorectal physiology, then biofeedback	YES — critical
Abdominal palpation	Detects faecal loading in left iliac fossa (doughy, indentable), suspicious mass (firm, fixed), hepatomegaly (metastatic disease). Faecal loading is soft and indentable; a malignant mass is hard and fixed.	Hard non-indentable mass → FIT plus urgent imaging (NICE NG12); same-day if obstruction or severe pain. Faecal loading only → disimpaction. Tenderness + distension → obstruction workup	YES — changes urgency
Perianal inspection	Detects anal fissure (posterior midline skin split — bright red blood on paper, severe pain), haemorrhoids, fistulae. Anal fissure managed with macrogol + topical GTN 0.4% — not just standard constipation treatment.	Anal fissure → topical GTN 0.4% (Rectogesic) + macrogol. Prolapsing haemorrhoids → referral for banding/surgical opinion	YES — changes management
Weight and general examination	Weight loss is a red flag — measure and document at every bowel complaint. Thyroid signs (bradycardia, dry skin, delayed reflexes) suggest hypothyroidism as secondary cause.	Unexplained weight loss → FIT (NG12); suspected cancer pathway referral if ≥10 µg Hb/g. Thyroid signs → TFTs urgently; treat hypothyroidism first	YES — changes urgency

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Key phrases that score

"I'd like to feel your tummy today — and I'd also like to offer an internal rectal examination, which can give us very useful information. You can decline that if you prefer, and I'd make sure you had a chaperone."

Deductions

Not offering DRE where it would change management (new, unexplained or refractory constipation, suspected impaction, bleeding or mass)
DRE performed without explaining it and checking consent — dignity and consent failure
Not weighing the patient when bowel symptoms are the presentation

🔴 Red

No examination at all. DRE not offered. Weight not measured. Laxative prescribed without physical assessment.

🟠 Amber

Abdominal exam mentioned but DRE not offered or offered without consent/chaperone. Weight not measured.

🟢 Green

Abdominal exam + DRE offered with explanation and consent. Chaperone offered. Weight measured. Findings linked to management decisions.

Step 4

Do I Need This Investigation?

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Most functional constipation requires no investigation. Investigations are indicated to exclude colorectal cancer (colonoscopy via a suspected cancer pathway referral), identify secondary causes (bloods), or assess refractory constipation (transit studies, anorectal manometry). Routine abdominal X-ray for constipation is NOT recommended — unreliable and does not change management for typical presentations.

Investigation	When to order — clinical indication	Result that changes management
Colonoscopy (suspected cancer pathway)	NICE NG12 criteria met: FIT ≥10 µg Hb/g after bleeding, bowel change, weight loss or IDA; or a rectal mass. Gold standard for CRC, polyps, IBD, and structural bowel disease.	Cancer → curative resection if early; staging if advanced. Polyps → polypectomy. Normal → reassure; manage as functional.
TFTs (thyroid function tests)	Any patient with constipation plus fatigue, weight gain, cold intolerance, hair loss, bradycardia. Hypothyroidism is one of the most commonly missed secondary causes of constipation.	TSH elevated → treat hypothyroidism; constipation often resolves without laxatives. Normal → thyroid not the cause.
FBC + iron studies	IDA at any age = NICE NG12 FIT criterion (suspected cancer pathway referral if ≥10 µg Hb/g). Also identifies anaemia from chronic blood loss.	IDA at any age → FIT (NG12); suspected cancer pathway referral if ≥10 µg Hb/g. Normal FBC in typical functional constipation → confirms no anaemia.
Corrected serum calcium	Hypercalcaemia causes constipation through smooth muscle depression. A simple blood test that prevents missing a significant metabolic abnormality.	Elevated → full hypercalcaemia investigation (see hypercalcaemia framework). Normal → excludes hypercalcaemia as cause.
Coeliac serology (anti-tTG IgA)	Coeliac disease can present with constipation and bloating mimicking IBS-C. Always exclude coeliac before diagnosing IBS-C.	Positive → duodenal biopsy; gluten-free diet. Negative → coeliac excluded; proceed with IBS-C management.
AXR (plain abdominal X-ray)	NOT routinely recommended for constipation. AXR cannot reliably quantify faecal loading. Useful only if bowel obstruction suspected (dilated loops, air-fluid levels) or volvulus being considered.	Dilated loops + obstruction pattern → 999. Coffee bean sign → sigmoid volvulus; emergency surgery. Normal AXR in simple constipation → no clinical value.

🎓 SCA Checkpoint — Step 4TasksGlobal Skills

Key phrases that score

"For typical constipation without warning signs, we don't need investigations — the diagnosis is clinical. Bloods aren't routine, but if anything suggests a thyroid, calcium or blood problem — or things don't settle — I'll check them."

Deductions

Ordering routine AXR for uncomplicated constipation — not indicated
Not checking TFTs/calcium when the history suggests a secondary cause (bloods are by context, not routine)
Ordering colonoscopy without NICE NG12 criteria being met

🔴 Red

Routine AXR ordered. No blood tests. Colonoscopy without indication.

🟠 Amber

Bloods ordered routinely without a clinical reason, or indicated bloods missed. No explanation to patient of investigation rationale.

🟢 Green

Clinical diagnosis made without unnecessary imaging. Bloods (TFTs, calcium, FBC) only where the history suggests a secondary cause, with rationale. Suspected cancer pathway referral applied if indicated.

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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Explaining constipation requires two things: reassurance that this is not cancer (if red flags are absent), and a clear mechanistic explanation of what is causing it. Patients with drug-induced constipation need to understand the mechanism to motivate them to take their laxative proactively rather than reactively.

🗣️ Diagnosis in Plain Language — opioid-induced constipation

"The codeine you're taking for your back is causing most of this constipation. Pain medications like codeine work by switching off pain signals in the brain — but they also switch off the signals that keep the bowel moving. Think of your bowel as having its own nervous system with a conveyor belt that normally keeps things moving along. Codeine slows that conveyor belt right down. This is completely treatable — and importantly, it's not a sign of anything more serious. I've specifically checked for the warning signs that would concern me, and none of those are present. What I want to do is prescribe something that works alongside the codeine to keep things moving."

💬 Addressing cancer fear directly

"Could this be bowel cancer?"
"That's really important to address. I've asked you specifically about blood in your stool and about weight loss — those are the two things that would concern me most, and both of those are absent. You also have a very clear drug cause in the codeine. Based on everything you've told me, I'm reassured this is the codeine causing the problem. That said, if at any point you develop any bleeding or lose weight without trying, I want you to come back immediately — that would completely change my approach. Does that feel clear?"

A — Diagnose and manage in primary care

Functional constipation (Rome IV)

≥2 features for ≥3 months: straining, hard stools, incomplete evacuation, <3/week, manual manoeuvres, sensation of blockage. No red flags. Lifestyle → ispaghula (bulk-forming) → macrogol ± stimulant.

Drug-induced constipation

Opioids, iron, CCBs (verapamil), TCAs, anticholinergics, antacids. Identify and modify. Macrogol + bisacodyl for OIC from day 1 of opioid.

IBS with constipation (IBS-C)

Abdominal pain ≥1 day/week for 3 months, associated with bowel change, relieved or worsened by defaecation. Low-FODMAP + targeted pharmacotherapy. Linaclotide if failed 12 months.

B — Secondary cause: investigate and refer

Hypothyroidism

TSH elevated. Treat with levothyroxine. Constipation often resolves without laxatives once thyroid is adequately treated. Most commonly missed secondary cause.

Pelvic floor dyssynergia

Straining, digitation, incomplete evacuation. Confirmed by specialist anorectal physiology (balloon expulsion, manometry) — not by DRE alone. Laxatives ineffective. Biofeedback is the primary treatment.

Coeliac disease

Anti-tTG positive + bowel symptoms + bloating. May mimic IBS-C. Gluten-free diet resolves symptoms. Always exclude before diagnosing IBS-C.

C — Emergency / suspected cancer pathway referral

Colorectal cancer

Red flags: bleeding, bowel change, weight loss or IDA → FIT, suspected cancer pathway referral if ≥10 µg Hb/g; rectal mass → suspected cancer pathway referral. Do not manage as functional without investigation.

Large bowel obstruction

No flatus + distension + vomiting. 999 surgical emergency. Never give laxatives if obstruction suspected.

🎓 SCA Checkpoint — Step 5TasksRelating to Others

Key phrases that score

"The codeine is switching off your bowel's conveyor belt signals — that's the direct cause of what you're experiencing."

"I've specifically checked for bleeding and weight loss — those are absent — and the cause is clearly the codeine."

Deductions

Not directly addressing the cancer fear — patient leaves still anxious
Using jargon without explanation
Not checking understanding after sharing the diagnosis

🔴 Red

Diagnosis given without addressing cancer fear. No analogy. Understanding not checked.

🟠 Amber

Correct diagnosis but cancer fear only partially addressed. Mechanism not explained. Understanding not checked.

🟢 Green

Conveyor belt analogy used. Cancer fear directly addressed with specific red flag screen reference. Understanding checked.

Step 6

If Referral Is Needed

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Most constipation is managed entirely in primary care. Referral is indicated for red flag symptoms (suspected cancer pathway), refractory constipation not responding to optimised primary care (gastroenterology), or specialist investigation (transit studies, anorectal manometry). Before labelling constipation as "refractory," ensure a genuine trial of macrogol + stimulant at adequate doses for a minimum of 4 weeks has been completed.

Indication	Urgency	GP does before referral	Must NOT do
NICE NG12 suspected cancer pathway referral criteria met	Suspected cancer pathway referral	Document the specific NG12 criterion; provide FBC result; document DRE findings; provide weight and weight loss data; start iron replacement if IDA present	Do not delay suspected cancer pathway referral to try laxatives first; do not reassure that haemorrhoids are the cause without FIT and appropriate investigation
Refractory constipation — failed primary care management	Routine gastroenterology	Document: treatments tried (names, doses, duration), secondary causes excluded (TFTs, calcium, coeliac normal), DRE findings. Ensure macrogol + stimulant for minimum 4 weeks at full dose before labelling refractory	Do not refer after 1-week trial of a low-dose single laxative; referral will be returned
Pelvic floor dyssynergia suspected	Gastroenterology/colorectal (anorectal physiology) → pelvic floor biofeedback	Document symptoms (straining, digitation, incomplete evacuation), DRE findings, failed laxatives. Biofeedback is the correct treatment — laxatives alone are ineffective for dyssynergia	Do not continue escalating laxatives when mechanism is obstructive
IBS-C failing first-line — linaclotide	Routine gastroenterology	Document: Rome IV IBS-C criteria, coeliac excluded, colonoscopy normal (if done), failed low-FODMAP + optimal laxatives from different classes, constipation for ≥12 months, mood screening (PHQ-9 + GAD-7)	Do not initiate linaclotide without gastroenterology advice; do not prescribe linaclotide for functional constipation without abdominal pain (IBS-C indication only)

🎓 SCA Checkpoint — Step 6Tasks

Key phrases that score

"I don't think a camera test is necessary right now — but if things don't improve, or if any warning signs develop, I would refer you immediately."

Deductions

Referring to gastroenterology at first presentation without primary care management trial
Not applying suspected cancer pathway referral when red flags indicate colonoscopy is warranted

Step 7

Management — Expectation · Goals · Lifestyle · Drug Cards · Follow-Up · Safety-Netting

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Management is stepwise: lifestyle first, then single laxative, then combination. Opioid-induced constipation requires macrogol + bisacodyl from day 1 of opioid therapy — lifestyle alone is insufficient. The most common error is prescribing a single laxative at a low dose for an inadequate duration and concluding it "doesn't work."

7A — Treatment goals

Treatment goals

BSS 3–5 stools, ≥3 per week, without straining Resolution of abdominal bloating and discomfort No recurrence of faecal impaction OIC: proactive bowel regime from day 1 of opioid Gradual, individualised fibre + adequate fluids (~1.5 L/day as a guide) Suspected cancer pathway referral (NG12) actioned if red flags present Secondary cause treated if identified (e.g. hypothyroidism) Lifestyle habits sustained — toilet routine, posture, exercise

Motivational language

"Once we get this sorted, you should feel genuinely better overall — the bloating, discomfort, and background worry takes up more energy than people realise until it's resolved."

"You've been managing this on your own for 6 months — you didn't need to. This is completely treatable."

7B — Non-medication management

💧

Fluid Intake

Around 1.5 L/day as a guide — individualise (heart failure, CKD, frailty)

Mechanism

Adequate fluid softens stool. Fibre absorbs water — insufficient fluid makes high-fibre foods worsen constipation. Fluid must be addressed before fibre is increased.

Practical

Carry a water bottle; replace coffee/tea with water; aim for pale yellow urine; start the day with a glass of water before caffeine.

Adequate hydration reduces stool transit time; essential for fibre to work

🥦

Dietary Fibre

Gradual, individualised increase in soluble fibre — no universal daily target

Mechanism

Insoluble fibre (vegetables, wheat bran) provides bulk. Soluble fibre (oats, pulses, fruit) feeds gut microbiome and promotes peristalsis. Sudden large increases cause bloating — gradual is essential.

Practical

Kiwi fruit has specific RCT evidence — 2 kiwis/day. Linseeds (1 tbsp/day): cheap and effective. Oats, lentils, tinned beans. Brown bread. Gradual increase over 2–3 weeks.

Soluble fibre can improve stool frequency; avoid big increases in impaction, slow transit or marked bloating (BDA 2025)

🚽

Toilet Habits and Posture

Target: respond to urge immediately; knees above hips

Mechanism

Suppressing the defaecation urge raises the threshold for the next urge — worsening constipation progressively. Optimal posture (knees above hips, leaning forward) straightens the anorectal angle and may make evacuation easier; no specific footstool height is evidence-based.

Practical

Respond to urge immediately. Use a footstool to raise knees. Sit on the toilet 20–30 min after breakfast (gastrocolic reflex) and allow time — do not rush. Restricted toilet access at work — encourage discussion with employer.

Footstool and gastrocolic-reflex timing: low-cost, low-risk practical measures

🏃

Physical Activity

Target: 30 min brisk walking daily; 150 min/week

Mechanism

Physical activity directly stimulates colonic peristalsis and increases parasympathetic nervous activity. Regular activity as able is a practical supportive measure.

Practical

Daily walking is most sustainable. Activity after meals exploits the gastrocolic reflex. Frame as therapeutic not cosmetic — the mechanism resonates with patients.

Regular activity as able — supportive alongside laxatives

💊

Review Constipating Drugs

Target: stop or switch where clinically safe

Mechanism

Drug-induced constipation is the most reversible cause. Not all drugs can be stopped, but all can be reviewed.

Practical

Opioids: cannot stop — add laxative. Iron: try ferrous fumarate or alternate-day; IV iron if oral not tolerated. CCBs: switch to amlodipine. TCAs: switch to SSRI if depression. Aluminium antacids: switch to PPI.

Drug review with modification or laxative co-prescribing resolves drug-induced constipation in 80% within 4 weeks

🧠

Stress and Psychological Wellbeing

Address anxiety or distress where present — not a routine constipation treatment

Mechanism

Chronic stress activates the sympathetic nervous system, reducing colonic motility. The gut-brain axis is bidirectional — constipation worsens anxiety and anxiety worsens constipation.

Practical

PHQ-9/GAD-7 where low mood or anxiety is suggested (and in IBS). NHS Talking Therapies referral for CBT if anxiety or depression identified. Hypnotherapy, CBT or psychological therapy: consider referral if IBS has not responded to drug treatment after 12 months (refractory IBS, NICE CG61).

CBT reduces IBS-C symptom severity by 35% at 12 months

7C — Laxative ladder

In practice: bulk-forming (ispaghula) first if diet alone is inadequate — but do not start it in opioid-induced constipation, impaction or suspected obstruction — then an osmotic (often macrogol), then add a stimulant if insufficient, then escalate to specialist agents within their NICE TA211 / TA345 / CG61 criteria. A stimulant alone suits soft stools with difficult evacuation or slow transit; long-term prescribed use can be appropriate with review. For OIC: a regular stimulant, osmotic or both (e.g. macrogol + bisacodyl) from day 1 of opioid therapy, by stool consistency.

Step 1 — Osmotic (first-line)

Macrogol (Movicol/Laxido) — 1–2 sachets daily in water

Preferred osmotic in practice — after ispaghula in functional constipation; first choice (with a stimulant) in opioid-induced constipation
Draws water into bowel by osmosis — softens and bulks stool
No tachyphylaxis; safe long-term; safe in pregnancy
Disimpaction: 4 sachets twice daily (8/day) for up to 3 days
Review at 4 weeks; if inadequate, add bisacodyl

Take each sachet in ≥250 ml water. Allow 72 hours for first effect. Target BSS type 4.

Step 2 — Add stimulant

Bisacodyl 5–10 mg nocte OR Senna 7.5–15 mg (1–2 tabs) nocte (add to macrogol)

Activates enteric nerves → stimulates peristalsis; onset 8–12 hours
Add to macrogol (not replace) if osmotic alone insufficient after 2–4 weeks
For OIC: macrogol + bisacodyl from day 1 of opioid — do not wait
Bisacodyl preferred over senna in elderly (gentler action)
Start with 5 mg bisacodyl; increase to 10 mg if needed

Long-term stimulant use can be appropriate when clinically indicated — review regularly; monitor for diarrhoea, dehydration and electrolyte disturbance.

Step 3 — Specialist agents (NICE TA211 / TA345 / CG61 criteria)

Prucalopride 2 mg OD: Women with chronic constipation; ≥2 laxatives from different classes at highest tolerated doses for ≥6 months have failed and invasive treatment is being considered (NICE TA211)
Naloxegol 12.5–25 mg OD: OIC with inadequate response to laxatives (NICE TA345: at least moderate symptoms despite ≥1 laxative class for ≥4 days in the prior 2 weeks); peripheral mu-receptor antagonist — does not affect central analgesia
Linaclotide 290 mcg OD: IBS-C only (not functional constipation); optimal or maximum tolerated doses of laxatives from different classes have not helped and constipation for ≥12 months (NICE CG61)

Document the NICE TA211 / TA345 / CG61 criteria before prescribing. Do not use linaclotide for functional constipation without abdominal pain.

7D — Medication options — guideline summary (no patient selection)

Situations this summary covers

Opioid-induced constipation — macrogol + bisacodyl from day 1; do not start bulk-forming
Faecal impaction — high-dose macrogol disimpaction regimen
Pregnancy — ispaghula + lactulose; avoid bisacodyl 1st trimester
IBS-C — low-FODMAP + macrogol; linaclotide if failed 12 months
Chronic functional constipation — macrogol 1–2/day
Anal fissure — macrogol + topical GTN 0.4%

Management approach

OIC: macrogol + bisacodyl from day 1 (not lifestyle alone). Impaction: macrogol 8 sachets/day × 3d then maintain. Pregnancy: ispaghula + lactulose. IBS-C: low-FODMAP first; linaclotide if failed 12 months. Anal fissure: macrogol + topical GTN 0.4%. Functional: macrogol step 1, add bisacodyl step 2.

Guideline summary — each situation is shown with what the guidance says for it, as written. Nothing is selected or worked out for an individual patient. Check doses in the current SPC and local formulary.

⚙ Interactive Medication Chooser — tick the patient profile, options re-tier live against the SPC and NICE TA211 / TA345 / CG61

A live, topic-scoped version of the standalone Medication Chooser. The static selector and reference cards below are unchanged.

7E — Drug reference cards

Macrogol (Polyethylene Glycol)

Movicol; Laxido; macrogol 3350 + electrolytes sachets

✓ First-line

First-line1–2 sachets daily in water

✓ Use when

Preferred osmotic in practice — after ispaghula in functional constipation; first choice (with a stimulant) in opioid-induced constipation

Faecal impaction — disimpaction regimen (4 sachets BD for up to 3 days)

OIC — macrogol + bisacodyl combination from day 1 of opioid

Pregnancy — safe (class A), no systemic absorption

✗ Avoid if

Suspected bowel obstruction — risk of perforation

⚠ Side effects

Bloating and cramping: usually transient, settles within 1 week

Diarrhoea if dose too high: reduce dose; target BSS type 4

🔬 Monitor

Stool consistency (BSS) and frequency — review at 4 weeks; adjust dose

💬 Counselling phrase

"These sachets draw water into the bowel to soften your stool — take each one in a large glass of water. Give it 2–3 days for the first effect, but at least a week to properly settle. The target is a stool that's soft and formed — not hard, not runny."

In SCA: macrogol as first-line (not lactulose) demonstrates current prescribing knowledge — a specific Tasks mark. For faecal impaction: "disimpaction regimen" — 8 sachets/day (4 twice daily) for up to 3 days — is a specific clinical knowledge point.

Bisacodyl

Dulcolax; 5 mg tablets; also 10 mg suppositories

✓ Step 2 add-on

Step 2 add-on5–10 mg nocte PO or 10 mg PR

✓ Use when

Add to macrogol if osmotic alone insufficient after 2–4 weeks

OIC: bisacodyl + macrogol from day 1 of opioid therapy — proactive not reactive

Slow transit constipation — stimulant needed to initiate peristalsis

✗ Avoid if

First trimester pregnancy (oral); long-term use only with regular review

⚠ Side effects

Abdominal cramping: dose-dependent; start 5 mg; take at night for morning effect

🔬 Monitor

Stool frequency and consistency at 2–4 week review

💬 Counselling phrase

"Take this tablet at night — it stimulates the bowel to move, so you'd usually go in the morning. It works alongside the macrogol sachets; the two together are much more effective for your type of constipation than either one alone."

In SCA: bisacodyl should be started on day 1 of opioid therapy alongside macrogol — NOT waited until constipation develops. This proactive approach demonstrates specific OIC knowledge and gains a Tasks mark.

Senna

Senokot; 7.5 mg tablets; 2 tablets = 15 mg standard dose

✓ Step 2 alternative

Step 2 add-on7.5–15 mg (1–2 tablets) nocte

✓ Use when

Alternative to bisacodyl as add-on stimulant; slightly more potent

Well-established in palliative care bowel regime alongside opioids

✗ Avoid if

Pregnancy (stimulant laxatives); long-term use without regular review

⚠ Side effects

Abdominal cramping: more than bisacodyl in some; start low (2 tabs); urine discoloration (harmless)

💬 Counselling phrase

"Take two tablets at night — the bowel usually moves 8–12 hours later. Your urine may turn slightly darker — that's harmless. Start with two tablets and increase if needed."

Naloxegol

Moventig; 12.5 mg and 25 mg tablets

✓ OIC Step 3

OIC Step 325 mg OD (12.5 mg in renal impairment or with interacting drugs)

✓ Use when

OIC with inadequate response to laxatives — at least moderate symptoms despite ≥1 laxative class for ≥4 days in the prior 2 weeks (NICE TA345)

Does NOT affect central analgesia — peripheral mu-receptor antagonist only; pain relief preserved

✗ Avoid if

Bowel obstruction; strong CYP3A4 inhibitors — significant drug interactions (check SPC)

⚠ Side effects

Abdominal pain, nausea, diarrhoea: common initially; usually settles in 2 weeks; warn about opioid-withdrawal symptoms

GI perforation: rare but serious — stop if sudden severe abdominal pain; report immediately

🔬 Monitor

Bowel frequency at 2–4 weeks; confirm opioid analgesia remains adequate

💬 Counselling phrase

"This medication specifically blocks the effect of the codeine on your bowel — without affecting the pain relief you get from it. Take on an empty stomach. It may cause cramping initially — that's the system getting moving again."

In SCA: naloxegol mechanism (peripheral mu-receptor antagonist, does not affect central analgesia) is a specific clinical knowledge point. NICE TA345 criteria: OIC with inadequate response to laxatives (≥1 laxative class for ≥4 days in the prior 2 weeks).

Prucalopride

Resolor; prucalopride succinate 2 mg tablets

✓ Slow transit Step 3

Step 32 mg OD (1 mg if elderly or eGFR <30)

✓ NICE TA211 criteria

Chronic constipation in women; ≥2 laxatives from different classes at highest tolerated doses for ≥6 months have failed and invasive treatment is being considered; prescribed by a clinician experienced in chronic constipation

5-HT4 agonist → directly stimulates colonic peristalsis throughout colon

✗ Avoid if

Bowel obstruction; severe hepatic impairment; pregnancy (insufficient data)

⚠ Side effects

Headache: most common (~15%); usually resolves by end of week 1

Nausea: take with food; usually settles within 2 weeks

🔬 Monitor

Review at 4 weeks — if no adequate improvement, discontinue (unlikely to benefit further). Annual review if continuing.

💬 Counselling phrase

"This tablet works on a specific receptor in the bowel — think of it as pressing the accelerator for your bowel's own movement. Take it in the morning; the most common side effect is a headache for the first few days, which usually passes."

In SCA: prucalopride requires NICE TA211 criteria documentation — ≥2 laxative classes failed at highest tolerated doses for ≥6 months, invasive treatment being considered, in a woman. Knowing the criteria gains a Tasks mark.

Linaclotide

Constella; 290 mcg capsules; once daily before food

✓ IBS-C Step 3

IBS-C Step 3290 mcg OD, 30 min before breakfast

✓ NICE CG61 criteria

IBS-C only — not for functional constipation without abdominal pain

Optimal or maximum tolerated doses of laxatives from different classes have not helped; constipation for ≥12 months

Guanylate cyclase-C agonist → increases intestinal fluid + reduces visceral pain — dual benefit

✗ Avoid if

Children under 18; bowel obstruction; functional constipation without abdominal pain criterion

⚠ Side effects

Diarrhoea: most common (~20%); take 30 min before first meal; usually settles by week 2

🔬 Monitor

Review at 4 weeks — if no improvement, stop. Annual review if continuing.

💬 Counselling phrase

"This capsule works specifically for IBS with constipation — it increases bowel fluid and also helps with the abdominal pain. Take it 30 minutes before your first meal. Diarrhoea is common in the first week — usually settles."

In SCA: linaclotide = IBS-C only, not functional constipation; NICE CG61 criteria = laxatives from different classes failed and constipation for ≥12 months. Prescribing it for functional constipation without abdominal pain would be incorrect.

7F — Follow-up schedule

4 weeks — Laxative response assessment

Review BSS, frequency (≥3/week target?), straining, bloating. If macrogol + lifestyle adequate: continue. If inadequate: add bisacodyl 5 mg nocte. Review blood test results (TFTs, calcium). Re-assess drug causes — has offending medication been modified? Rescreen red flags.

Action pointEscalation decision

8–12 weeks — Sustained response or escalation

If macrogol + bisacodyl achieving BSS 3–5: reassess whether lifestyle is now sufficient. If IBS-C and inadequate response: low-FODMAP dietitian referral; PHQ-9 + GAD-7 for mood. If refractory: document treatments tried for referral letter.

Sustained response review

6 months — Specialist referral decision

Refer by clinical need, not a fixed 6-month wait (severe symptoms, recurrent impaction, suspected defaecatory dysfunction, neurological disease, nutritional impact): gastroenterology for transit studies and/or anorectal manometry. Women: if NICE TA211 criteria are met, document them — prucalopride is prescribed by a clinician experienced in chronic constipation. Review opioid — can dose be reduced or agent switched?

Specialist referral

Annual — Chronic constipation review

Document current stool pattern and laxative dose. Review drug causes. Check TFTs and calcium only if the history suggests a secondary cause. Rescreen for red flags at every annual review — cancer risk increases with age. Apply suspected cancer pathway referral if any red flag develops.

Annual reviewRed flag rescreen

Each opioid prescription — OIC review

Every opioid prescription review must include an explicit bowel habit assessment. If macrogol + bisacodyl not achieving BSS 3–5: escalate to naloxegol (NICE TA345). If opioid dose increased: increase laxative dose proportionally. Document bowel regime in opioid review.

OIC management

7G — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific safety-net phrases

4 weeksLaxative response review — BSS, frequency, red flag rescreen, escalation decision

Immediately if red flagsRectal bleeding or weight loss = prompt review and FIT (suspected cancer pathway referral if ≥10 µg Hb/g; a lower FIT does not close the case if concern persists) — do not wait for routine appointment

6 months / AnnualSpecialist referral if refractory; prucalopride if criteria met; annual red flag rescreen

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

"So to summarise: the codeine is causing your constipation, and I'm prescribing macrogol sachets — one daily in a large glass of water — and bisacodyl at night. I'd also like you to increase your water intake significantly and respond to the urge to go as soon as it comes. Let's review in 4 weeks. Does that feel clear?"

"If you ever notice blood or lose weight without trying — come back immediately; don't wait for the 4-week appointment."

"Give the macrogol at least 2–3 days before expecting a result."

"Is there anything else on your mind?"

Deductions — closing

Lactulose chosen for OIC — may cause bloating and is less suitable in opioid-induced constipation
OIC managed with lifestyle advice alone — insufficient for opioid bowel dysfunction
No red flag safety-net for rectal bleeding and weight loss — medico-legal critical omission
DRE not offered or discussed when it would change management
Cancer fear not directly resolved
Closing question absent

Tasks domain — full closing criteria

Red flags screened: no bleeding, no weight loss documented
Drug cause identified (codeine) and managed (macrogol + bisacodyl)
Macrogol as first-line (not lactulose)
Bisacodyl added for OIC from first prescription
Red flag safety-net: bleeding/weight loss = immediate return + suspected cancer pathway referral
Obstruction emergency safety-net given
4-week follow-up booked

Relating to Others — full closing criteria

Embarrassment acknowledged early and explicitly
Cancer fear named and directly resolved with red flag screen reference
Conveyor belt analogy used for mechanism
Understanding checked during explanation
Quality of life impact acknowledged
Closing question asked

🔴 Red

Lactulose first-line. No red flag safety-net. OIC managed with lifestyle only. Cancer fear ignored. No follow-up booked. Closing question absent.

🟠 Amber

Macrogol prescribed but bisacodyl not added for OIC. Red flag safety-net too vague. Cancer fear acknowledged but not specifically resolved. Follow-up mentioned but not booked.

🟢 Green

Macrogol + bisacodyl for OIC. Cancer fear directly addressed with specific red flag screen reference. Specific red flag safety-net. 4-week follow-up booked. Closing question asked.

"I've been having trouble with my bowels for about 6 months and I've been embarrassed to come in. I've been trying to sort it out myself with some stuff from the chemist but it's not really working."

Who you are

Linda Patel, 52 years old, office administrator. Opening bowels every 3–4 days with hard, lumpy stools requiring significant straining. Has had this since starting codeine phosphate 30 mg QDS for chronic lower back pain (prescribed 7 months ago). Tried Fybogel OTC — minimal improvement. Tried Senna for 5 days — temporary improvement then back to normal. Drinks 5–6 cups of coffee/tea daily, very little water. Sedentary office job. Low-fibre diet. No rectal bleeding. No weight loss. No family history of bowel cancer she knows of. Takes amlodipine 5 mg for hypertension. BMI 27.

Hidden agenda

Worried it might be bowel cancer — her aunt was diagnosed with bowel cancer last year. She has not mentioned this to anyone. She will not volunteer the cancer fear unless specifically asked about concerns. If the GP directly asks "is there something you're worried this might be?" she will disclose it. If the GP then addresses it with the specific red flag screen ("no blood, no weight loss, and a clear drug cause"), she becomes significantly calmer and much more engaged with the management plan.

Symptoms if asked directly

Stool frequency: every 3–4 days (was daily before codeine)
Stool consistency: BSS type 1–2; significant straining
No blood in stool, no blood on paper
No unintentional weight loss; weight stable
Significant afternoon bloating
No abdominal pain that comes before opening bowels
Holds on at work — toilets are shared and not private

Bonus details

If asked about holding the urge at work: "Yes — I hold it until I get home because the toilets aren't very private" (opens toilet habit advice)
If asked fluid intake: mainly 5–6 coffees, maybe 1–2 glasses water
Does not consider supplements a "medication" — won't volunteer Fybogel unless asked specifically about OTC preparations

"I've been using Fybogel for weeks and it hasn't done much — is there something stronger I can have? And honestly, do you think I need a camera test?"

Resolution criteria: Linda will be satisfied if the candidate (1) acknowledges embarrassment; (2) directly addresses the cancer fear with red flag screen reference ("no blood, no weight loss, clear drug cause"); (3) explains the codeine mechanism with conveyor belt analogy; (4) prescribes macrogol + bisacodyl and stops the Fybogel (bulk-forming is not used in opioid-induced constipation); (5) gives specific lifestyle advice (fluid, toilet habit); (6) gives specific red flag safety-net ("come back immediately if bleeding or weight loss").

🏥

Clinic Quick Reference

Constipation — Clinical Decision Framework

NICE NG12 · Rome IV

▼expand

🚦 1 — Triage

🔴 Emergency / suspected cancer pathway referral

999: bowel obstruction (no wind + distension + vomiting)

999: cauda equina (bowel change + leg symptoms)

FIT: bleeding, weight loss or bowel change → suspected cancer pathway referral if ≥10 µg Hb/g

IDA at any age → FIT; BSG: upper and lower GI investigation

Suspected cancer pathway referral: palpable abdominal or rectal mass

🟠 Urgent — same-day / days

Faecal impaction → macrogol disimpaction regimen

Suspected hypothyroidism / hypercalcaemia → urgent bloods

Constipation in malignancy → palliative care bowel regime

🟢 Routine — Primary Care

Functional constipation (Rome IV, no red flags)

Drug-induced (opioids, iron, CCBs, TCAs)

IBS-C (Rome IV IBS criteria)

Review at 4 weeks after starting laxative

📊 2 — Key Numbers

Macrogol first

Preferred first-line in practice — not lactulose; not bisacodyl alone

FIT

Bleeding, weight loss, IDA or bowel change → FIT; suspected cancer referral if ≥10 µg Hb/g

Day 1 OIC

Start macrogol + bisacodyl on day 1 of opioid — proactive

BSS 3–5

Target stool consistency on treatment

4 weeks

Adequate trial before escalation to add bisacodyl

Fibre

Gradual, individualised soluble fibre — no universal daily target

Disimpaction

Macrogol 8 sachets/day (4 BD) for up to 3 days

Naloxegol

OIC: inadequate response to ≥1 laxative class taken ≥4 days in the prior 2 weeks (TA345)

Prucalopride

Women, ≥6 months failed macrogol + stimulant

Linaclotide

IBS-C only; failed 12 months first-line

No AXR

Abdominal X-ray not indicated for typical constipation

TFTs + Ca

By context, not routine — check when the history suggests a secondary cause

💊 3 — Laxative Ladder

Standard Ladder

Step 1: Macrogol 1–2 sachets/day

Step 2: Add bisacodyl 5–10 mg nocte or senna 7.5–15 mg nocte

Step 3 (women, ≥6 months): Prucalopride 2 mg OD

OIC Step 3: Naloxegol 12.5–25 mg OD

IBS-C Step 3 (≥12 months): Linaclotide 290 mcg OD

⚠ Never give laxatives if obstruction suspected

Special Situations

OIC → macrogol + bisacodyl from day 1 of opioid (proactive)

Impaction → macrogol 8 sachets/day × 3 days then maintain

Pregnancy → ispaghula + lactulose; avoid bisacodyl 1st trimester

Anal fissure → macrogol + topical GTN 0.4% (Rectogesic)

Hypothyroidism → treat thyroid first; constipation may resolve

Dyssynergia → biofeedback physiotherapy; laxatives alone ineffective

⚠ 4 — Safety Netting

Follow-up timeline

4 weeks: Laxative response; red flag rescreen; escalation decision

8–12 weeks: Sustained response; mood screen for IBS-C

Refractory: Gastroenterology by clinical need (not a fixed 6-month wait); prucalopride criteria

Annual: Red flag rescreen; drug cause review

Each opioid Rx: Bowel habit + OIC regimen review

🎓

SCA Exam Quick Reference

SCA Consultation Blueprint

Tasks · Relating to Others · Global Skills · RAG guide

▼expand

🕐 12-Minute Flow

0–2 min

Normalise + Open

"This can be an awkward topic — you've done the right thing. Tell me in your own words what's been happening."

GSRO

✗ Jumping straight to symptoms without acknowledging embarrassment

2–6 min

Red Flags + Drug History + ICE

"Any blood? Any weight loss? What medications are you taking — any painkillers? Is there something you're worried this might be?"

TasksRO

✗ Not asking about bleeding · ✗ Not asking about drugs · ✗ Missing cancer fear

6–7 min

Examination

"I'd like to examine your tummy and offer an internal rectal examination — you can decline, and I'd ensure you had a chaperone."

Tasks

✗ Not offering DRE when indicated · ✗ No weight measurement

7–10 min

Diagnosis + Cancer Fear + Plan

"The codeine is switching off your bowel's conveyor belt — and I've checked for the warning signs of something serious; those are absent. I'm prescribing macrogol sachets and bisacodyl."

TasksRO

✗ Cancer fear not resolved · ✗ Lactulose instead of macrogol

10–12 min

Safety-Net + Follow-Up + Close

"Bleeding or weight loss = come back immediately. 4-week review booked. Is there anything else?"

TasksRO

✗ Generic safety-net · ✗ No follow-up booked · ✗ No closing question

🔴🟠🟢 RAG Scoring

Tasks

🟢

Red flags fully screened; drug cause + macrogol + bisacodyl for OIC; DRE offered with consent; specific red flag safety-net; 4-week follow-up

🟠

Bleeding asked but weight loss not screened; lactulose prescribed; bisacodyl not added for OIC; safety-net too vague

🔴

No red flag screen; drug cause missed; lactulose or senna alone; no safety-net; no follow-up

Relating to Others

🟢

Embarrassment acknowledged; cancer fear named and resolved with red flag screen; conveyor belt analogy; understanding checked; closing question

🟠

ICE partially explored; cancer fear acknowledged but not specifically resolved; understanding not checked

🔴

Embarrassment ignored; ICE absent; cancer fear ignored; patient leaves still anxious

💬 Key Phrases

Open

"These things can be awkward — you've done the right thing raising it. Tell me in your own words what's been happening."

Cancer fear

"I've specifically checked for blood and weight loss — those are absent — and the cause here is clearly the codeine."

Mechanism

"The codeine is switching off the conveyor belt signals in your bowel."

Laxative

"Macrogol draws water into the bowel — give it 2–3 days for first effect, a week to properly settle."

Safety-net

"If you ever notice blood or lose weight without trying — come back immediately."

🚫 9 Danger Zones

✗

Not asking about rectal bleeding
→ Single most important red flag in any bowel presentation

✗

Lactulose as first-line
→ Macrogol is the preferred first-line osmotic; lactulose causes bloating, is slower

✗

OIC managed with lifestyle alone
→ Requires macrogol + bisacodyl from day 1 of opioid

✗

Cancer fear not addressed
→ Must name and resolve with specific red flag screen reference

✗

DRE not offered / no consent
→ Offer where it changes management; always with explanation, consent and chaperone

✗

Red flag safety-net absent or generic
→ Name bleeding and weight loss specifically as immediate return triggers

✗

Routine AXR ordered
→ Not indicated for uncomplicated constipation

✗

Stimulant alone into impaction or hard stools
→ Exclude impaction first; add an osmotic for hard stools; stimulant alone suits soft stools with difficult evacuation

✗

Closing question absent
→ Always end with "Is there anything else on your mind?"

💊 Drug Quick-Pick

Functional constipation, mild

→

Macrogol 1–2/day

Step 1

Insufficient at 4 weeks

→

Add bisacodyl 5–10 mg nocte

Step 2

Opioid-induced constipation

→

Macrogol + bisacodyl day 1

Proactive

Faecal impaction

→

Macrogol 8 sachets/day × 3d

Disimpaction

OIC, laxatives inadequate

→

Naloxegol 12.5–25 mg OD

NICE TA345

IBS-C failed ≥12 months

→

Linaclotide 290 mcg OD

IBS-C only

⛔ No lactulose first-line · Osmotic or stimulant by stool type · Red flag rescreen every appointment · FIT for bleeding, weight loss or bowel change

Constipation · GP Clinical Reasoning Framework v2 · NICE NG12 Suspected cancer: recognition and referral (updated April 2026) · NICE TA211 Prucalopride (2010) · NICE TA345 Naloxegol (2015) · NICE CG61 Irritable bowel syndrome in adults (updated 2017) · Rome IV Criteria (2016; international) · BSG iron deficiency anaemia guideline (2021)

v3: Dual tailored summaries · Macrogol-first laxative ladder · OIC proactive management · suspected cancer pathway referral criteria explicit · Embarrassment and cancer fear as SCA RO domain elements

Teaching clinicians why each step matters — not just what to do · Always consult current SPC · Clinical judgement takes precedence

Constipation

Red Flags

999 or Same-Day / suspected cancer pathway referral

Same-Day / Days

Primary Care Management

Functional constipation (Rome IV)

Drug-induced constipation

IBS with constipation (IBS-C)

Hypothyroidism

Pelvic floor dyssynergia

Coeliac disease

Colorectal cancer

Large bowel obstruction

4 weeks — Laxative response assessment

8–12 weeks — Sustained response or escalation

6 months — Specialist referral decision

Annual — Chronic constipation review

Each opioid prescription — OIC review

⚠ Three scenario-specific safety-net phrases

🎭 Patient actor brief — click to practise

Who you are

Hidden agenda

Symptoms if asked directly

Bonus details