What is the next line of treatment for a constipated patient after ingestion of paraffin wax?

Management of Constipation After Failed Paraffin Wax Treatment

After failure of paraffin wax milkshake for constipation, the next line treatment should be stimulant laxatives (such as bisacodyl or senna) or osmotic laxatives (such as polyethylene glycol), with rectal measures (suppositories or enemas) if oral treatments fail. 1

Assessment of Failed Treatment

• Evaluate for fecal impaction through digital rectal examination before proceeding with next-line treatments 1
• Liquid paraffin (paraffin wax) has potential disadvantages including minimal efficacy and safety issues such as aspiration risk and perianal burning 1
• Avoid continued use of liquid paraffin, especially in bed-bound patients or those with swallowing disorders due to risk of aspiration pneumonia 1, 2

Next Line Treatment Options

Oral Agents (First Choice)

• Osmotic Laxatives:

  • Polyethylene glycol (PEG) 17g/day dissolved in 4-8 oz of beverage is highly recommended as next step 1, 3
  • PEG produces bowel movement typically within 1-3 days and has excellent safety profile 3
  • Lactulose is an alternative but may cause bloating and takes 2-3 days for effect 1
  • Magnesium salts (hydroxide, citrate) can be used with caution in patients with normal renal function 1

• Stimulant Laxatives:

  • Bisacodyl 10-15mg 2-3 times daily with goal of one non-forced bowel movement every 1-2 days 1
  • Senna taken in the evening to produce morning bowel movement 1
  • These stimulate colonic motility and are particularly useful when osmotic agents alone are insufficient 1

Rectal Measures (If Oral Agents Fail)

• Suppositories:

  • Glycerin suppositories act as rectal stimulant and can be used if oral treatments fail 1
  • Bisacodyl suppositories twice daily may be effective 1

• Enemas:

  • Consider small-volume enemas if oral treatments and suppositories fail 1
  • Isotonic saline enemas are preferred, especially in older adults 1
  • Phosphate enemas should be used with caution due to potential electrolyte disturbances 1

Special Considerations

• For Fecal Impaction:

  • If impaction is present, perform digital fragmentation and extraction of stool, followed by maintenance bowel regimen 1
  • Manual disimpaction may be required under anesthesia in severe cases 1

• For Opioid-Induced Constipation:

  • If constipation is opioid-induced and persists despite standard laxatives, consider methylnaltrexone (0.15mg/kg every other day) 1
  • Peripherally acting mu-opioid receptor antagonists (PAMORAs) may be valuable in unresolved opioid-induced constipation 1

Treatments to Avoid

• Do not continue with liquid paraffin due to risk of aspiration pneumonia and minimal efficacy 1, 2, 4
• Avoid bulk laxatives (psyllium) in non-ambulatory patients with low fluid intake due to risk of mechanical obstruction 1
• Avoid docusate sodium as there is inadequate experimental evidence supporting its use in constipation management 5

Monitoring and Follow-up

• Aim for one non-forced bowel movement every 1-2 days 1
• Monitor for adverse effects including abdominal cramping, electrolyte disturbances, and dehydration 1
• If constipation persists despite these measures, consider referral for specialized testing (colonic transit studies, anorectal manometry) 1