What is the management plan for constipation?

Management Plan for Constipation

The management of constipation should begin with lifestyle modifications and fiber supplementation, followed by osmotic laxatives, stimulant laxatives, and specialized medications for refractory cases. 1

Initial Assessment and Non-Pharmacological Approaches

Assessment

• Evaluate for possible causes of constipation (medications, metabolic disorders, mechanical obstruction)
• Physical examination should include abdominal examination, perineal inspection, and digital rectal examination (DRE) 1
• Plain abdominal X-ray may be useful to assess fecal loading and exclude bowel obstruction in severe cases 1

Lifestyle Modifications

• Ensure privacy and comfort during defecation
• Optimize positioning (use a footstool to assist with defecation)
• Increase fluid intake, particularly water
• Increase physical activity and mobility within patient limits
• Schedule toileting attempts 30 minutes after meals to take advantage of the gastrocolic reflex 1, 2
• Educate patients to attempt defecation at least twice daily and strain no more than 5 minutes 1
• Consider abdominal massage to reduce gastrointestinal symptoms and improve bowel efficiency 1

Dietary Changes

• Increase dietary fiber intake to approximately 20-25g per day 2, 3
• Focus on soluble fiber sources (psyllium) rather than insoluble fiber 4
• Gradually increase fiber intake over several weeks to minimize bloating and flatulence 1, 4

Pharmacological Management

First-Line: Fiber Supplements

• Psyllium is the most effective fiber supplement and can be used as first-line therapy 1, 4
• Ensure adequate hydration with fiber supplementation 1
• Avoid bulk laxatives in non-ambulatory patients with low fluid intake due to risk of mechanical obstruction 1

Second-Line: Osmotic Laxatives

• Polyethylene glycol (PEG) is the preferred osmotic laxative with good efficacy and safety profile 1, 2, 4
• For elderly patients, PEG (17g/day) offers an efficacious and tolerable solution 1
• Other options include lactulose or magnesium salts (use magnesium salts cautiously in renal impairment) 1

Third-Line: Stimulant Laxatives

• Options include senna, cascara, bisacodyl, and sodium picosulfate 1
• Can be used in patients with mobility limitations 1, 2
• Be aware of potential side effects including abdominal cramping and pain 1

Fourth-Line: Secretagogues

• Linaclotide can be considered for chronic idiopathic constipation when other treatments fail 5, 6
• Effective for increasing complete spontaneous bowel movements (CSBMs) 5

Special Situations

Opioid-Induced Constipation (OIC)

• All patients receiving opioid analgesics should be prescribed a concomitant laxative unless contraindicated by pre-existing diarrhea 1
• Osmotic or stimulant laxatives are generally preferred 1
• Avoid bulk laxatives such as psyllium for OIC 1
• For unresolved OIC, consider peripheral opioid antagonists such as methylnaltrexone or naloxegol 1, 6

Fecal Impaction

• Management involves disimpaction (digital fragmentation and extraction of stool) 1
• Follow with enema (water or oil retention) or suppository to facilitate passage through the anal canal 1
• After disimpaction, implement a maintenance bowel regimen to prevent recurrence 1, 2
• Suppositories and enemas are preferred first-line therapy when DRE identifies a full rectum or fecal impaction 1

Elderly Patients

• Pay particular attention to assessment of elderly patients 1
• Ensure access to toilets, especially for those with decreased mobility 1
• Provide dietetic support 1
• Avoid liquid paraffin for bed-bound patients and those with swallowing disorders (risk of aspiration) 1
• For swallowing difficulties or repeated fecal impaction, consider rectal measures (enemas and suppositories) 1
• Isotonic saline enemas are preferable in older adults due to fewer adverse effects 1

Monitoring and Follow-up

• Regular monitoring for response to treatment
• Adjust treatment based on response
• For patients with chronic kidney/heart failure on diuretics or cardiac glycosides, monitor for dehydration and electrolyte imbalances 1

Common Pitfalls to Avoid

• Using bulk laxatives in patients with inadequate fluid intake
• Prescribing magnesium-based laxatives long-term due to potential toxicity 6
• Failing to provide prophylactic laxatives when starting opioid therapy
• Using sodium phosphate enemas in elderly patients (prefer isotonic saline enemas) 1
• Neglecting to implement a maintenance bowel regimen after treating fecal impaction