Constipation

Constipation. This is a boring subject? I disagree. How many patients you see in a shift, elderly, peds or adults and the final diagnosis is constipation? I would say a significant amount. You might know how to deal with “acute” constipation but what is the best way to deal with chronic constipation so they will not bounce back in your emergency department the week after?

Let’s do a quick review of constipation management. This refer to a very good article about constipation and elderly that you should read (references below) (1).

What is constipation? There are some criteria (Rome III criteria) to define constipation. Normally, bowel movement will vary between 3/day and 3/week. Or you can define it by a change of normal habit for a person. Whatever you like.

Investigation will be in order to rule out other cause of constipation like intestinal obstruction, acute abdomen, metabolic disorders (hypercalcemia) or hypothyroidism. Also an abdominal xray is debatable. Another important thing is to review the medication (see, medication matters!!). Try to find out if these medications could be d/c: antiacids, calcium supplements, iron supplements, antihistamines and other anticholinergics, tricyclic antidepressants, calcium-channel blockers, opioids, antiparkinsonian agents.

Most importantly, a digital rectal exam is mandatory to rule out a fecal impaction that will greatly change your acute management.

Ok, there is no fecal impaction (or you evacuated it), just pure constipation. What now?

You should always talk about good hydration, exercise and alimentation (fibres, fruits and vegetables) but there is no literature around it! What can be bad about this, nothing. It is like the fact that having a parachute when jumping out of a plane is not evidence based for survival!

For constipation treatment, you have a few options: osmotic agents, bulk agents and stimulants.

The most studied are osmotic agents (ex: PEG, or lactulose). The mechanism of action is promoting water secretion by the colon. Patient should take this once or twice a day, regularly and it will works in a few days. When they became more regular, they can take this forever! There is not addiction to it. Laxaday is a large amount of fluid (2 glasses of water), and lactulose has a very sweet taste. This is the first line.

The second line would be stimulants. They increase the intestinal motility and colonic secretion of mucus and water. They work very well when the patient is on opioids or anticholinergique or other medication that affect the intestinal motility. The downside of this is the lack of efficacy when long-term use and the cramping and bloating associated.

Bulk agents like psylium (non absorbable soluble dietary fibres). They increase the volume of stool, colonic distension and promote better mechanical movement. There is no RCT for elderly though that supports the use of bulk agents in constipation. Could worth a trial though.

Other classes include stool softener (sodium docusate), they does not work. Prokinetic agents might be working but no good evidences supporting their use yet. Suppository and enema are more reserved for acute constipation and fecal impaction resistant to your manual “debulkage”. Biofeedback? Sure.

Finally, if you are planning to follow these folks or refer them to the family physicain, make sure they make a diary of their bowel movement. I found that elderly are more closed to their bowels, healthy bowel healthy life? Now you know everything! Questions? No, ok good let’s talk about something else!

 

Reference

  1. Gandell D, Straus SE, Bundookwala M, Tsui V, Alibhai SM. Treatment of constipation in older people. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2013 May 14;185(8):663-70. PubMed PMID: 23359042. Pubmed Central PMCID: 3652936.

 

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