What laxative is suitable for a patient with right upper quadrant abdominal pain?

From the Guidelines

I would not recommend giving a laxative to a patient with right upper quadrant abdominal pain without first determining the cause of the pain. Right upper quadrant pain could indicate serious conditions like gallbladder disease, hepatitis, or even appendicitis that would not be appropriately treated with laxatives. In fact, administering a laxative could potentially worsen certain conditions or mask important symptoms needed for diagnosis. The patient should be evaluated by a healthcare provider to determine the cause of the pain through a proper history, physical examination, and possibly imaging studies or laboratory tests. If constipation is determined to be the cause of the pain after appropriate medical evaluation, then specific laxative recommendations could be made based on the patient's medical history and condition, with osmotic laxatives such as polyethylene glycol (PEG)-3350 being a potential option 1. Right upper quadrant pain is often related to the liver, gallbladder, or biliary tract, and these organs are not primarily affected by constipation, which typically causes discomfort in the lower abdomen. Some key points to consider when evaluating the patient include:

• The patient's medical history and current medications
• The severity and duration of the abdominal pain
• Any associated symptoms such as nausea, vomiting, or fever
• The results of any diagnostic tests, such as imaging studies or laboratory tests. Unless the patient has a clear diagnosis of constipation, it is not recommended to prescribe laxatives, especially bulk laxatives such as psyllium, which are not recommended for opioid-induced constipation (OIC) 1.

From the FDA Drug Label

STOP USE AND ASK A DOCTOR IF • you have rectal bleeding or your nausea, bloating, cramping or abdominal pain gets worse. These may be signs of a serious condition. The patient has right upper quadrant abdominal pain, which may be a sign of a serious condition.

• The label advises to stop use and ask a doctor if abdominal pain gets worse.
• It is recommended to consult a doctor before administering any laxative, including polyethylene glycol (PO), to a patient with abdominal pain 2.

From the Research

Laxative Options for Right Upper Quadrant Abdominal Pain

• The use of laxatives for patients with right upper quadrant abdominal pain should be approached with caution, as the underlying cause of the pain needs to be determined 3, 4.
• There is no direct evidence to support the use of laxatives specifically for right upper quadrant abdominal pain, as the primary focus is on diagnosing and treating the underlying cause of the pain.

Evidence-Based Laxative Recommendations

• Polyethylene glycol (PEG) and senna are recommended as first-line laxatives for chronic constipation, with good evidence (grade A) supporting their use 5, 6, 7.
• Other laxatives, such as psyllium, lactulose, bisacodyl, and magnesium salts, have moderate evidence (grade B) supporting their use for chronic constipation 5, 6, 7.
• It is essential to note that the evidence for laxative use is primarily based on studies for chronic constipation, and the application to right upper quadrant abdominal pain may not be directly relevant.

Considerations for Laxative Use

• The patient's medical history, physical examination, laboratory testing, and diagnostic imaging should be taken into account before administering any laxatives 3, 4.
• Common adverse events associated with laxative use include diarrhea, nausea, bloating, and abdominal pain 6, 7.