From the Guidelines
For overflow diarrhea, a treatment approach focusing on clearing the impacted stool and promoting complete evacuation is crucial, rather than solely relying on anti-diarrheal medications, which can worsen the condition. The primary goal is to address the underlying cause of the overflow diarrhea, which is often a fecal impaction. According to the study by 1, a meticulous characterization of bowel habits and circumstances surrounding fecal incontinence (FI) is essential. For patients with diarrhea, a careful dietary history to identify ingestion of poorly absorbed sugars and/or caffeine, followed by a trial of elimination, is recommended.
In terms of medication, starting with loperamide (2 mg) 30 minutes before breakfast and titrating as necessary up to 16 mg daily can help manage diarrhea. Additionally, fiber supplementation can be used to improve stool consistency and reduce diarrhea-associated FI, as noted in the study by 1. It's also important to consider the potential for bile-salt malabsorption in patients with idiopathic diarrhea, in which case cholestyramine or colesevelam may be helpful.
For patients with constipation, laxatives and anorectal testing to identify evacuation disorders are recommended. Pelvic floor biofeedback therapy can be effective in addressing underlying rectal evacuation disorders, and rectal cleansing with a small enema or tap water can reduce the likelihood of stool leakage. A gentle osmotic laxative regimen, such as polyethylene glycol (MiraLAX), can be used to clear impacted stool, and stimulant laxatives like bisacodyl (Dulcolax) can be added if needed to enhance bowel movements. Maintaining adequate hydration by drinking at least 8 glasses of water daily during treatment is also essential.
Key considerations in managing overflow diarrhea include:
- Clearing the impacted stool causing the condition
- Promoting complete evacuation
- Avoiding anti-diarrheal medications that can worsen the impaction
- Increasing dietary fiber gradually to prevent recurrence
- Maintaining good hydration
- Seeking medical attention promptly if symptoms persist or worsen.
From the Research
Treatment for Overflow Diarrhea (Encopresis)
- The treatment for overflow diarrhea (encopresis) typically involves addressing the underlying cause of constipation and fecal loading 2.
- Senna-based laxatives have been shown to be effective in managing overflow retentive stool incontinence in pediatrics, with the dose and duration of treatment correlated with parameters measured from an initial contrast enema 2.
- A digital rectal examination should be performed to rule out fecal impaction and overflow incontinence, and stool softeners or laxatives should be discontinued if there is no impaction but a weak anal sphincter 3.
- Medications such as loperamide or diphenoxylate/atropine may be useful for diarrhea with incontinence, while laxatives such as polyethylene glycol, lactulose, or senna may be effective for constipation 3, 4, 2.
Management of Constipation
- Treatment goals for constipation include improving symptoms and restoring bowel function by accelerating colonic transit and facilitating defecation 5.
- Food and dietary changes, exercise, and lifestyle changes should be the first step in management, followed by laxatives if necessary 5.
- Bulking agents such as psyllium, bran, or methylcellulose may be used, followed by osmotic laxatives such as lactulose, polyethylene glycol, or lactitol if response is poor 5.
- Stimulant laxatives such as bisacodyl, sodium picosulphate, or senna may be indicated if osmotic laxatives are not effective 5.
Considerations for Treatment
- The primary aim of intervention in patients with chronic constipation is to better manage the underlying condition along with management of constipation 5.
- The physician should explain the rationale for prescribing laxatives and educate patients about the potential drawbacks of long-term use of laxatives 5, 6.
- Treatment should be tailored to the underlying mechanism(s) and needs of each patient, and may involve a combination of lifestyle changes, dietary modifications, and medication 3, 5, 2.