Gastroenterology Today Autumn 2020

FEATURE
RETHINKING HOW WE TREAT
CONSTIPATION IN THE UK
Professor Anton Emmanuel, Consultant Gastroenterologist at UCLH and the National Hospital for Neurology & Neurosurgery
In 2018 alone, the UK’s national health system (NHS) saw more
than 52,000 emergency hospital admissions for constipation –
the cost of which adds up to a staggering £71 million per year. 1
Managing such avoidable costs out of the healthcare system
is now even more of a priority given the effects of the Covid-19
pandemic and its aftermath. The NHS urgently needs nonconsultation
pathways to transform sufferers’ lives, yet also
minimise impact on precious resources.
Pyramid” which clearly plots an effective course of treatment. The pyramid
diagram shows that effective treatment of constipation should be done in
incremental stages whereby patients are moved further up the treatment
ladder until their condition comes under control. Starting from the base
layer of the pyramid, patients will first begin treatment with the most
conservative options such as adjustment of diet and fluid intake, lifestyle
alteration oral medications including stool softeners and laxatives, digital
stimulation, suppositories and biofeedback.
GASTROENTEROLOGY TODAY - AUTUMN 2020
We have to start from the question, “why is an easily manageable and
treatable condition like constipation resulting in such a high number
of unplanned emergency hospital admissions?”. The emergency
admission numbers demonstrate the urgent need to revise the current
treatment for constipation and prevent so many cases from escalating
into unwanted admissions. Unplanned hospital visits could certainly be
reduced if symptoms were identified and dealt with at the primary care
stage, but many healthcare professionals lack the right information to
effectively treat the condition. In fact, beyond standard interventions
such as laxatives and dietary changes, there is little supporting
material to guide healthcare professionals through the next stages of
treatment. Drawing on the Bowel Interest Group’s (BIG) newly published
management pathway, this article seeks to help bridge this information
gap by underlining best practices in bowel management.
One of the first barriers to effective treatment of constipation is its
perceived taboo nature. The stigma attached to constipation means that
people are suffering in silence needlessly until the condition becomes
too difficult to bear. Patients are reluctant to share symptoms with their
doctor at the early stages of the condition – with as many as one in
five stating they would be too embarrassed to talk about it at all 2 – and
therefore receive less timely treatment than they should. In parallel, the
high prevalence of these symptoms results in it being perceived by some
healthcare professionals as low risk and of minor significance, further
delaying treatment. Unfortunately, this potentially sets the stage for more
invasive interventions and unwanted hospital admissions in the long run.
With bowel behaviour serving as an important indicator of our health,
it is crucial that we break down this wall and promote more open
conversations about bowel health. Greater awareness about constipation,
as well as correct advice and treatment, will help to make people feel
more comfortable talking to their GP. Without intervention, people with
bowel disorders can suffer from reduced quality of life including feelings
of embarrassment, anxiety and depression – as well as a number of
unwanted side-effects such as urinary tract infections (UTIs). Failure to
deal with symptoms promptly can lead to more complex problems such
as haemorrhoids, anal fissures or rectal prolapse, so it is important to
diagnose and treat the condition as early as possible.
The next step is ensuring that healthcare professionals themselves are
sufficiently informed about treatment options for constipation. In support,
the Bowel Interest Group has developed a ‘Bowel Dysfunction Treatment
If these standard interventions are not effective within the prescribed
three-month period, patients would typically then progress onto the next
stage of treatment: minimally invasive treatment options such as transanal
irrigation (TAI). It is important that the prescribed length of treatment is
consistently adhered to at every level and that patients are moved up the
pyramid once the given timeframe has elapsed. This ensures that patients
suffering from constipation can reach the appropriate therapy level and
resume their normal lives as quickly as possible. The upper layers of the
treatment pyramid are comprised of more invasive treatment options such
as nerve stimulation implants and surgical colonic irrigation. Finally, the
last recourse if these are ineffective, is the creation of a permanent stoma
– which constitutes the peak of the pyramid.
Another important consideration for GPs and Clinical Commissioning
Groups is the cost associated with each therapy. BIG’s pyramid diagram
provides this valuable information, sub-categorized into the one-off cost,
the annual cost and the 7-year cost for each treatment. For instance,
while the cost of standard starting treatment should amount to £2,539,
this figure can reach up to £32,298 over seven years if practitioners do not
progress their patients up the pyramid towards more effective treatment
within the recommended timeframe. 3 Respecting the designated
timeframe for each treatment echelon therefore makes sense from both a
patient-outcome perspective as well as from a financial outlook.
Bowel management in the UK is in need of urgent reform, despite
pockets of excellence scattered across the country. Today, constipation
is often perceived as low priority despite having a hugely detrimental
impact on the patients it affects, as well as the financial burden that its
ineffective treatment imposes on the healthcare system. Having the right
pathways in place at the primary level is crucial to ensuring patients
do not require unplanned emergency interventions within already
overstretched facilities. The Covid-19 experience has served to highlight
even further the requirement for non-consultation pathways to transform
sufferers’ lives, yet also minimise impact on precious resources.
Securing these outcomes will take a nationwide effort to rebuild our
understanding of the management of constipation.
Please find the Bowel Interest Group’s full report - Dealing with Chronic
Constipation: Information for General Practitioners:
https://bowelinterestgroup.co.uk/resources/dealing-with-chronicconstipation-information-for-general-practitioners/
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1
Bowel Interest Group, Cost of Constipation Report, Second edition, 2019
2
Ibid
3
Bowel Interest Group, Dealing with Chronic Constipation: Information for General Practitioners, 2020