How to manage a patient with a moderate fecal burden in the colon?

From the Guidelines

To manage a patient with moderate fecal burden in the colon, a gradual increase in fiber intake and the use of an osmotic agent, such as polyethylene glycol or milk of magnesia, is recommended as the initial step. This approach is supported by the American Gastroenterological Association's medical position statement on constipation 1. The guideline suggests that polyethylene glycol (17 g daily) or milk of magnesia (1 oz twice daily) can be used to soften stool and stimulate evacuation, with an approximate daily cost of $1 or less.

Some key considerations for managing moderate fecal burden in the colon include:

• Gradually increasing fiber intake through diet and supplements
• Using osmotic agents like polyethylene glycol or milk of magnesia
• Adding a stimulant laxative, such as bisacodyl or glycerol suppositories, if necessary
• Considering newer agents like lubiprostone or linaclotide if symptoms do not respond to initial treatments
• Biofeedback therapy as an option for patients with defecatory disorders, which has been shown to improve symptoms in over 70% of patients 1

It is essential to tailor the treatment approach to the individual patient's symptoms and needs, and to consider underlying causes of fecal burden, such as medication side effects or mobility issues, to prevent recurrence. As noted in the guideline, the motivation of the patient and therapist, as well as the frequency and intensity of the retraining program, can contribute to the success of biofeedback therapy 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. ASK A DOCTOR BEFORE USE IF YOU HAVE • nausea, vomiting or abdominal pain • a sudden change in bowel habits that lasts over 2 weeks • irritable bowel syndrome

To manage a patient with a moderate fecal burden in the colon, the following steps should be taken:

• Stop use of any laxatives and ask a doctor if the patient experiences rectal bleeding, or if nausea, bloating, cramping, or abdominal pain worsen, as these may be signs of a serious condition 2.
• Consult a doctor before use of polyethylene glycol (PO) if the patient has nausea, vomiting, or abdominal pain, or if there is a sudden change in bowel habits that lasts over 2 weeks, or if the patient has irritable bowel syndrome 2. The patient should be advised to seek medical attention if they experience any of these symptoms or if they need to use a laxative for longer than 1 week 2.

From the Research

Management of Moderate Fecal Burden in the Colon

To manage a patient with a moderate fecal burden in the colon, several strategies can be employed based on existing evidence:

• Dietary Changes: Increasing dietary fiber intake can help increase stool frequency and reduce laxative use 3. However, it's essential to note that high amounts of insoluble fiber can worsen digestive symptoms, and soluble fibers like psyllium may be more beneficial 4.
• Fluid Supplementation: Adequate fluid intake is crucial, and water supplementation can enhance the effect of a high-fiber diet on stool frequency and laxative consumption 3.
• Polyethylene Glycol (PEG): PEG with or without electrolytes is an effective and safe treatment for functional constipation, and it can be used as a first-line treatment 5. The combination of PEG and psyllium may offer additional benefits 4.
• Bisacodyl: Using bisacodyl before PEG solution can reduce the volume of PEG required for bowel preparation and improve patient tolerance 6.
• Bowel Stimulation Regimen: A regimen combining a fiber-rich diet, fluid, physical activity, and a prokinetic drug can help reduce fecal load, improve defecation, and alleviate symptoms 7.

Considerations for Treatment

When managing a patient with a moderate fecal burden, it's essential to consider the following:

• Individualized Approach: Treatment should be tailored to the patient's specific needs and symptoms.
• Monitoring and Follow-up: Regular monitoring and follow-up are necessary to adjust the treatment plan as needed and ensure the patient's symptoms are improving.
• Potential Complications: Patients with a high fecal load or prolonged colon transit time may be at risk for complications such as appendicitis, hemorrhoids, or colon cancer, and should be closely monitored 7.