How to manage moderate to marked fecal loading in a 79-year-old patient with no signs of bowel obstruction?

From the Guidelines

For a 79-year-old patient with moderate to marked fecal loading without bowel obstruction, I strongly recommend initiating treatment with oral osmotic laxatives, such as polyethylene glycol (PEG 3350, Miralax) 17g mixed in 8oz of water once or twice daily for 3-7 days, as this approach has been shown to be efficacious and tolerable in elderly patients 1.

When managing moderate to marked fecal loading in elderly patients, it is crucial to consider their unique needs and potential comorbidities. The following steps can be taken:

• Ensure the patient has access to toilets, especially if they have decreased mobility 1
• Provide dietetic support to manage known decreases in food intake, which can negatively influence stool volume and consistency 1
• Optimize toileting by educating patients to attempt defecation at least twice a day, usually 30 minutes after meals, and to strain no more than 5 minutes 1
• Consider the patient's medical history, drug interactions, and potential adverse effects when selecting laxatives 1

The use of PEG (17 g/day) is a recommended approach for elderly patients due to its good safety profile 1. Additionally, stimulant laxatives like bisacodyl (Dulcolax) 5-10mg orally daily or senna 8.6mg tablets, 2 tablets at bedtime, can be used, but it is essential to be aware of the potential risks of pain and cramps.

If the patient has swallowing difficulties or repeated fecal impaction, rectal measures such as enemas and suppositories can be the preferred choice of treatment 1. Isotonic saline enemas are preferable in older adults due to the potential adverse effects of sodium phosphate enemas in this age group.

After initial disimpaction, maintenance therapy should include:

• Increased fluid intake (at least 6-8 glasses of water daily)
• Dietary fiber (aim for 25-30g daily)
• Regular physical activity as tolerated
• Possibly a daily stool softener like docusate sodium 100mg twice daily

It is also essential to address underlying causes of constipation, such as medication side effects (particularly opioids, anticholinergics, calcium channel blockers), mobility issues, and inadequate fluid intake, to prevent recurrence 1.

From the Research

Management of Moderate to Marked Fecal Loading

• In a 79-year-old patient with no signs of bowel obstruction, management of moderate to marked fecal loading can be challenging due to the potential for underlying health issues and reduced organ system reserve 2.
• The use of polyethylene glycol (PEG) solutions has been shown to be effective in treating fecal impaction, with low doses having fewer side effects than lactulose 3.
• A study using GoLytely oral solution in patients with refractory fecal impaction found that all patients were able to regularly pass feces and show radiographical colorectal clearing within 6-57 hours, with no significant complications observed 4.
• Another study evaluating the efficacy and safety of PEG plus electrolytes in the treatment of severe constipation and fecal impaction found that 89.3% of patients had a successful response to treatment, with a low incidence of adverse events 5.

Treatment Options

• Polyethylene glycol (PEG) solutions, such as Movicol, can be used to treat severe constipation and fecal impaction, with a dose of up to eight 13.8g sachets per day over three days 5.
• GoLytely oral solution can be administered at a rate of 100ml/hr per os, via nasogastric tube, or via gastrostomy tube, to relieve fecal impaction in patients refractory to conventional medical treatment 4.
• It is essential to note that the incidence of adequate bowel preparation in elderly patients is not optimal, and factors such as non-compliance with dietary instructions, non-compliance with PEG dosage, and walking <30 minutes during preparation can increase the risk of inadequate bowel preparation 6.

Considerations

• Elderly patients with fecal impaction may present with atypical symptoms, such as circulatory, cardiac, or respiratory symptoms, rather than typical gastrointestinal symptoms 2.
• The diagnosis of fecal impaction should be recognized and treated promptly to prevent progression of symptoms and potential life-threatening complications 2.