How to manage constipation in a patient after a cervical fracture?

Management of Constipation After Cervical Fracture

Osmotic or stimulant laxatives are the first-line treatment for constipation in patients with cervical fracture, with polyethylene glycol (PEG) being the preferred option due to its efficacy and safety profile. 1

Assessment of Constipation in Cervical Fracture Patients

• Perform physical examination including abdominal examination, perineal inspection, and digital rectal examination (DRE) to assess for fecal impaction 1
• Evaluate medication list for constipation-inducing drugs, particularly opioid analgesics
• Consider checking corrected calcium levels and thyroid function if clinically suspected 1
• Plain abdominal X-ray may be useful to assess fecal loading and exclude bowel obstruction in severe cases 1

Prevention and Self-Care Strategies

• Ensure privacy and comfort for normal defecation
• Optimize positioning (use a small footstool to assist with gravity and pressure)
• Increase fluid intake within patient limits
• Increase activity and mobility as tolerated (even bed to chair transfers) 1
• Abdominal massage can be beneficial in reducing gastrointestinal symptoms and improving bowel efficiency, particularly in patients with neurogenic problems 1, 2

Pharmacological Management

First-Line Options:

• Osmotic laxatives:

  • Polyethylene glycol (PEG): 17g in 8 oz of water twice daily 1
  • Lactulose
  • Magnesium salts (use cautiously in renal impairment) 1

• Stimulant laxatives:

  • Senna
  • Bisacodyl (10-15mg daily)
  • Sodium picosulfate 1

For Opioid-Induced Constipation:

• Always prescribe a prophylactic laxative regimen when starting opioids 1
• Avoid bulk-forming laxatives such as psyllium, which are ineffective and may worsen constipation 1
• For refractory opioid-induced constipation, consider peripheral μ-opioid receptor antagonists:
  • Methylnaltrexone (12mg subcutaneously once daily) 1, 3
  • Naloxegol
  • Naldemedine 1

Management of Fecal Impaction

If DRE identifies fecal impaction:

• Suppositories and enemas are preferred first-line therapy 1
• Digital fragmentation and extraction of stool may be necessary 1
• Follow disimpaction with maintenance bowel regimen to prevent recurrence 1

Contraindications for Enemas:

• Neutropenia or thrombocytopenia
• Paralytic ileus or intestinal obstruction
• Recent colorectal or gynecological surgery
• Recent anal or rectal trauma
• Severe colitis, inflammation, or infection of the abdomen 1

Escalation of Therapy

If constipation persists:

• Reassess for bowel obstruction or hypercalcemia 1
• Add or rotate between different laxative classes
• Consider opioid rotation to fentanyl or methadone if opioid-induced 1
• For severe refractory constipation, peripheral μ-opioid receptor antagonists (methylnaltrexone, naloxegol, naldemedine) can be used as rescue therapy 1, 3

Special Considerations for Cervical Fracture Patients

• Mobility limitations require special attention to positioning and assistance with toileting
• Monitor for autonomic dysreflexia in patients with cervical injuries (can be triggered by constipation)
• Ensure adequate fluid intake while respecting any fluid restrictions
• Maintain regular timing for bowel movements to establish a routine
• Consider the impact of neurogenic bowel dysfunction in spinal cord injury

By following this structured approach to constipation management in cervical fracture patients, you can effectively prevent and treat this common complication, improving patient comfort and quality of life while reducing the risk of complications.