Constipation in adults — KFP-style written assessment

KFP 1 (10 marks)

A 47-year-old teacher presents with a two-year history of constipation: three bowel motions weekly, hard stools requiring straining, occasional incomplete evacuation. No bleeding, weight loss or anaemia. FBC, calcium, TSH normal. Diet poor in fibre; fluid intake low; desk-bound job.^{[10] [9]}

1. Does she meet Rome IV criteria? Justify. (3) ^[10]
2. Prescribe the foundation treatment with specifics. (4) ^[9]
3. She returns at six weeks partially improved. What is step two? (3) ^[5]

Model answers

1. Yes: Rome IV requires at least two of straining in ≥25% of defecations, lumpy/hard Bristol 1-2 stools, blockage sensation, incompleteness, manual manoeuvres, fewer than three spontaneous bowel motions weekly — she meets straining, hard stools, and borderline frequency, with no IBS loose-stool pattern. ^[10]
2. Foundation therapy per BDA guideline structure: soluble fibre supplement (e.g. psyllium) titrated slowly from ~5 g daily toward 20-30 g total daily fibre with adequate fluid to avoid gas and bloating; kiwifruit (two fruits daily) or prunes as evidence-supported food options; magnesium oxide as an additional evidence-backed supplement option; regular unhurried toilet time after breakfast exploiting the gastrocolic reflex; increased incidental exercise. The BDA guideline issued 59 statements covering fibre supplements, probiotics, magnesium oxide, kiwifruit supplements and foods including prunes and rye bread. ^[9]
3. Add a first-line osmotic laxative: macrogol (PEG) one to three sachets daily titrated to effect. Randomised head-to-head comparison showed PEG produced faster therapeutic effect than lactulose at weeks one and two, though final effect was similar — PEG is preferred when speed matters. Review at four weeks; escalate only if optimised dosing fails. ^[5]