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Treatment of Severe Constipation Sorbitol, lactulose, or electrolyte-free polyethylene glycol-containing solution may be given after bowel cleansing to produce one stool at least every other day. The patient is instructed to use the bathroom after meals to take advantage of meal-stimulated increases in colonic motility. Biscaodyl or glycerine suppository is administered if there is no defecation after two days, to prevent recurrence of fecal impaction.An alternative is to use enemas
Softeners
Stimulant
Bulkers
-Bulk forming laxatives: psyllium seed, methylcellulose, and calcium polycarbophil- absorb water and increase fecal mass.- increase stool frequency and soften Stool softeners (eg docusate sodium) lower surface tension of stool, thereby allowing water to more easily enter the stool. Less effective than laxatives Stimulant laxatives (eg bisacodyl and senna) alter electrolyte transport by the intestinal mucosa and increase intestinal motor activity. Side effects: Hypokalemia, protein losing enteropathy, and salt overload. There is no convincing evidence that chronic use of stimulant laxatives causes structural or functional impairment of the colon Dietary changes: — For normal transit constipation -Fluids and fibre are the most effective therapy (clear dose response between fibre intake, water intake, and fecal output) - Cereal fibres generally possess cell walls that resist digestion and retain water within their cellular structures- also, the large particle size of cereal products enhances fecal bulking effects. - Citrus fruit fibre and legumes stimulate the growth of colonic flora, thereby increasing fecal mass - Wheat bran is one of the more effective fibre laxatives- 2 tablespoons raw bran with water for each meal is effective -The recommended amount of dietary fibre is 20 to 35 g/day. - Sorbitol/ fructose containing foods also beneficial
Hyperosmolar laxatives (bulk up stool)— The saline laxatives (eg milk of magnesia) - poorly absorbed hyperosmolar agents.Can cause hypermagnaesia esp in renal failure Lactulose is a synthetic disaccharide which is not metabo - lized by intestinal enzymes; thus, water and electrolytes remain within the intestinal lumen due to the osmotic effect of the undigested sugar. Requires some time (24 to 48 hours) to achieve its effect Polyethylene glycol electrolyte solutions A reasonable approach is to start with 17 gm once daily and titrate up or down (to a maximum of 34 gm daily) to effect. There is no need to use PEG more than once daily. If patients do not respond, one can decrease PEG to 17 gm daily and add a stimulant laxative every other to every third day as needed.
Treatment of constipation in adults Initial Management
Written by Dr Sebastian Zeki
Patient education — Increase fluid and fibre intake Use normal postprandial increases in colonic motility by instructing patients to defecate after meals (esp in mornings) Impaction 1.Manually disimpact 2.Enema with mineral oil will help to soften the stool and provide lubrication for the rest. 3.If unuccessful, use a water soluble contrast enema (Gastrografin or Hypaque) administered under fluoroscopy to assure absence of any obstruction and to eliminate more proximal impactions. 4.Occasionally, fractionation of impacted stool beyond the reach of the finger must be accomplished using flexible or rigid sigmoidoscopy with instrumentation. 5.Then use daily enemas for up to three days, or by drinking a balanced electrolyte solution containing polyethylene glycol until cleansing is complete. These approaches have achieved a 78% success rate
Behavioral approaches — Esp in chidren/ demented or with physical impairments Biofeedback — In dyssynergic defecation. Doesnt benefit patients with slow-transit constipation Pharmacologic therapy — Some patients with severe constipation have been treated successfully with misoprostol (a prostaglandin analog) regular doses of polyethylene glycol electrolyte solutions, or colchicine. Lubiprostone — Lubiprostone is a locally acting chloride channel activator that enhances chloride-rich intestinal fluid secretion. Can be very effective but is trial Tegaserod — Tegaserod (Zelnorm), a partial 5-HT4 receptor agonist, was approved for constipation-predominant irritable bowel syndrome in women under age 55 and for chronic idiopathic constipation but removed from the market in March 2007 because of cardiovascular side-effects. Botulinum toxin —USS guided injection of type A botulinum toxin into both sides of the puborectalis muscle can be effective in dyssynergic defecation. May need repeats Surgery Colectomy — Subtotal colectomy with ileorectal anastomosis Criteria: 1. Chronic, severe, and disabling symptoms from constipation that are unresponsive to medical therapy. 2. Slow colonic transit of the inertia pattern. 3. No intestinal pseudoobstruction, as demonstrated by radiologic or manometric studies. 4. No prominent abdominal pain Other surgical approaches — Improved rectal evacuation when pressure is placed on the posterior wall of the vagina during defecation should be demon - strated before considering a rectocele repair. In addition, tests to exclude dyssynergic defecation should be done prior to surgery. Hospitalized Patients Bisacodyl 10 mg PO at night with one or two glasses of water/ 1 bisacodyl suppository per rectum may be given during the day. Magnesium citrate or magnesium hydroxide given in the AM are acceptable alternatives, even in the presence of opiates. In patients who are having bowel movements that are hard or uncomfortable, we suggest docusate daily for stool softening. Alternative Therapies For Chronic Constipation
