eMedicine Specialties > Emergency Medicine > Gastrointestinal
Constipation: Treatment & Medication
Updated: Aug 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
- Most patients have chronic constipation, which does not lend itself to a specific etiology at time of presentation.
- A comprehensive history should readily identify the most common causes of fecal impaction including (1) postoperative constipation, (2) prolonged bed rest, (3) residual barium from barium enemas, or (4) medication-related constipation (eg, opioids, anticholinergics).
- In elderly bedridden patients, it is important to exclude severe dehydration and electrolyte abnormalities.
- Exclude any life-threatening complication of constipation (eg, volvulus) and remember that the patient might present with intestinal perforation after tap water enemas performed at home.
- Specifically focus therapeutic interventions on facilitating rectal evacuation rather than increasing bowel movement.
- Evaluation and treatment guidelines on constipation are available from the American Society of Colon and Rectal Surgeons.1
Consultations
- Consult a general surgeon if you suspect intestinal obstruction, perforation or volvulus.
Medication
The mainstay of treatment of constipation is a high-fiber diet. Bulking agents usually are the next line of treatment. Enemas can be used to assist in complete stool evacuation. Avoid irritant or peristaltic stimulants (eg, senna). Chronic use has been reported to induce damage to the myenteric plexus, which may eventually impair bowel motility.
Bulk-forming agents
These agents are used to increase fecal mass, which stimulates peristalsis.
Psyllium (Metamucil, Fiberall)
Promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.
Adult
1 tsp PO tid with 8 oz of liquid
Pediatric
<6 years: Not established
6-12 years: Administer half of adult dose with 8 oz of liquid
>12 years: Administer as in adults
May decrease absorption and effects of salicylates, nitrofurantoin, tetracyclines, and diuretics
Documented hypersensitivity; fecal impaction, intestinal obstruction, colonic atony, undiagnosed abdominal pain
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in intestinal adhesions, ulcers, or stenosis
Methylcellulose (Citrucel)
Promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.
Adult
1 tbsp PO qdaily/tid with 8 oz of liquid
Pediatric
<6 years: Not established
6-12 years: Administer half of adult dose with 8 oz of liquid
>12 years: Administer as in adults
May decrease absorption and effects of salicylates, nitrofurantoin, tetracyclines, and diuretics
Documented hypersensitivity; fecal impaction, colonic atony, intestinal obstruction, undiagnosed abdominal pain
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in intestinal adhesions, ulcers, or stenosis
Emollients or softeners
Lower surface tension of stool and allow mixing of aqueous and fatty substances, thereby softening stool.
Docusate sodium (Colace, Surfak)
Allows the incorporation of water and fat into stool causing softening of stool.
Adult
100 mg PO qdaily/bid
Pediatric
<3 years: 10-40 mg/d PO qdaily or divided bid/qid
>3-6 years: 20-60 mg/d PO qdaily or divided bid/qid
6-12 years: 40-150 mg/d PO qdaily or divided bid/qid
>12 years: Administer as in adults
Decreases effects of warfarin and increases effects of phenolphthalein
Documented hypersensitivity; nausea, vomiting, acute abdominal pain
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Prolonged use of medication may result in electrolyte imbalance
Emollient stool softeners in combination with stimulants
Emollient stool softeners cause stool to soften. Stimulants increase peristaltic activity in the GI.
Docusate sodium and casanthranol combination (Peri-Colace, Diocto C, Silace-C)
Docusate sodium allows incorporation of water and fat into stool causing stool to soften.
Casanthranol is an anthraquinone stimulant hydrolyzed by colonic bacteria into active compound. Usually produce action 8-12 h after administration.
Adult
1-2 cap or tab PO qdaily/bid
Alternatively, 5-60 mL PO qd if syrup or emulsion given
Pediatric
<6 years: Not recommended
>6 years: Administer as in adults
Decreases effects of warfarin and increases effects of phenolphthalein
Documented hypersensitivity; nausea, vomiting, GI bleeding, appendicitis, GI bleeding, congestive heart failure, fecal impaction, appendicitis, nausea, vomiting, acute abdominal pain
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Excessive use may lead to electrolyte imbalance, osteomalacia, steatorrhea, and cathartic colon
Osmotic laxatives
These agents act by retaining fluid in the bowel, osmosis, or altering the pattern of water distribution in feces.
Magnesium hydroxide (Phillips' Milk of Magnesia)
Causes osmotic retention of fluid, which distends colon and increases peristaltic activity. This in turn promotes emptying of the bowel.
Adult
15-30mL PO qdaily/bid
Pediatric
2.5-5 mL PO prn up to qid
Decreases effects of tetracyclines, digoxin, indomethacin, and iron salts
Documented hypersensitivity; colostomy, ileostomy, renal failure, fecal impaction, appendicitis
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Caution in severe renal impairment
Sodium phosphate (Fleet enema)
Through osmotic effects, these agents draw water from the intestine into the lumen of the gut, producing distention and promoting bowel emptying.
Adult
1 adult (4.5 fl oz) enema PR
Pediatric
1 pediatric (2.25 fl oz) enema PR
Do not administer aluminum, magnesium antacids, or sucralfate
Documented hypersensitivity; hypernatremia, hyperphosphatemia, renal failure, hypocalcemia, fecal impaction
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hypocalcemia, hyperphosphatemia, hypernatremia, and acidosis in patients with renal difficulties; caution in congestive heart failure and cirrhosis
Polyethylene glycol solution (MiraLax)
For treatment of occasional constipation. In theory, less risk of dehydration or electrolyte imbalance with isotonic polyethylene glycol compared with hypertonic sugar solutions. Laxative effect generated because polyethylene glycol is not absorbed and continues to hold water by osmotic action through small bowel and colon, resulting in mechanical cleansing.
Supplied with measuring cap marked to contain 17 g of laxative powder when filled to indicated line. May require 2-4 d (48-96 h) to produce bowel movement.
Adult
Dissolve 17 g in 8 oz of water and drink daily prn for up to 2 wk
Pediatric
Not established
May decrease absorption of oral medications, thereby reducing effectiveness
Documented hypersensitivity; colitis, ileus, megacolon, bowel perforation, gastric retention, GI obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in ulcerative colitis and hot loop polypectomy; not for use > 2 wk
Lactulose (Cephulac, Cholac, Constilac)
Produces an osmotic effect in the colon, resulting in distention and promoting peristalsis. Action may take up to 48 h.
Adult
15-30 mL PO qdaily/bid
Pediatric
<1 year: 2.5 mL PO bid
1-5 years: 5 mL PO bid
6-12 years: 10 mL PO bid
>12 years: Administer as in adults
Decreases effects of neomycin, laxatives, and antacids
Documented hypersensitivity; galactosemia, intestinal obstruction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adverse effects include flatulence, cramps, and abdominal discomfort; caution in diabetes mellitus; monitor for electrolyte imbalance
Gastrointestinal Agent, Miscellaneous
These agents may assist in increasing GI motility.
Lubiprostone was the focus of a study by Sweetser et al on colonic sensory and motor function.2 No overall effects of lubiprostone were noted on the end points of compliance, fasting tone, motility indexes, or sensation. However, a treatment-by-sex interaction for compliance was noted in women (P = 0.02). Lubiprostone induced a decreased fasting compliance in women (P = 0.06) and an overall decreased colonic tone contraction after a standard meal relative to fasting tone (P = 0.014), with greater effect in women (P < 0.01). Sweetser et al concluded that lubiprostone did not increase colonic motor function.
Lubiprostone (Amitiza)
Locally acting chloride channel activator that enhances a chloride-rich intestinal fluid secretion without altering sodium and potassium concentrations in the serum. Specifically activates C1C-2, an apical membrane in the human intestine. Increases intestinal fluid secretion to assist in GI motility, thereby decreasing symptoms of chronic idiopathic constipation (eg, abdominal pain, bloating, straining, hard stools).
Adult
24 mcg PO bid with food
Pediatric
Not established
Data limited, none reported
Documented hypersensitivity; history of mechanical GI obstruction; severe diarrhea
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Common adverse effects include headache, nausea, diarrhea, abdominal pain, vomiting and abdominal distension; discontinue if diarrhea persists
5-HT4 Receptor partial agonists
These agents may stimulate peristaltic activity by partially activating serotonin type 4 receptors. Tegaserod was temporarily withdrawn from the US market in March 2007; however, as of July 27, 2007, restricted use of tegaserod is now permitted via a treatment investigational new drug (IND) protocol. The treatment IND will allow tegaserod treatment of irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease.
In 2007, tegaserod marketing was suspended because of a meta-analysis of safety data pooled from 29 clinical trials that involved more than 18,000 patients. The results showed an excess number of serious cardiovascular adverse events, including angina, myocardial infarction, and stroke, in those taking tegaserod compared with placebo. In each study, patients were assigned at random to either tegaserod or placebo. Tegaserod was taken by 11,614 patients, and placebo was taken by 7,031 patients. The average age of patients in these studies was 43 years, and most patients (ie, 88%) were women. Serious and life-threatening cardiovascular adverse effects occurred in 13 patients (0.1%) treated with tegaserod; among these, 4 patients had a heart attack (1 died), 6 had unstable angina, and 3 had a stroke. Among the patients taking placebo, only 1 (0.01%) had symptoms suggesting the beginning of a stroke that went away without complication. For more information, see the FDA MedWatch Product Safety Alert.
Tegaserod (Zelnorm)
Available in US by restricted treatment IND for irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Serotonin type 4 (5-HT4) receptor partial agonist with no affinity for 5-HT3 receptors. May trigger peristaltic reflex via 5-HT4 activation, which enhances basal motor activity and normalizes impaired GI motility. Research studies have shown inhibitory activity of the drug on visceral activity in the GI tract.
Adult
6 mg PO bid ac
Pediatric
Not established
None reported
Documented hypersensitivity; moderate or severe renal impairment; history of bowel obstruction, symptomatic gallbladder disease, suspected sphincter of Oddi dysfunction, or abdominal adhesions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Diarrhea may occur (do not give to patients with diarrhea); discontinue if new or sudden worsening of abdominal pain or diarrhea occurs (do not give to patients with diarrhea); ischemic colitis and other forms of intestinal ischemia have been reported rarely (causality has not been established); discontinue immediately if ischemic colitis (eg, rectal bleeding, bloody diarrhea, new or worsening abdominal pain) occurs and evaluate immediately, do not resume treatment if findings consistent with ischemic colitis
More on Constipation |
| Overview: Constipation |
| Differential Diagnoses & Workup: Constipation |
 Treatment & Medication: Constipation |
| Follow-up: Constipation |
| Multimedia: Constipation |
| References |
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References
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Sweetser S, Busciglio IA, Camilleri M, Bharucha AE, Szarka LA, Papathanasopoulos A, et al. Effect of a Chloride Channel Activator, Lubiprostone, on Colonic Sensory and Motor Functions in Healthy Subjects. Am J Physiol Gastrointest Liver Physiol. Nov 25 2008;[Medline].
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Further Reading
Keywords
hard stool, constipation, constipation treatment, constipation causes, constipation symptoms, fecal impaction, irregular bowel movement, straining, colonic functional disorder, anorectal functional disorder, functional constipation, pain on defecation, rectal bleeding, thrombosed hemorrhoids, intussusception, irritable bowel syndrome, idiopathic slow transit constipation, chronic intestinal obstruction, rectal outletobstruction, anismus, solitary rectal ulcer, rectocele, weak pelvic floor, Hirschsprung disease
