What is the treatment for a patient with constipation lasting 3 days?

Treatment for 3 Days of Constipation

For a patient with constipation lasting 3 days, the recommended first-line treatment is to increase fluid intake, dietary fiber, and physical activity, followed by polyethylene glycol (PEG) if these measures are insufficient. 1

Initial Non-Pharmacological Approaches

• Increase fluid intake, especially for those with low baseline fluid consumption 1
• Increase dietary fiber if the patient has adequate fluid intake and physical activity 1
• Encourage appropriate physical exercise when possible 1
• Consider a trial of fiber supplementation (particularly psyllium) for mild constipation as it is low-risk, low-cost, and easily accessible 1

Pharmacological Management

First-Line Medications

• Polyethylene glycol (PEG) 17g mixed in 8 ounces of liquid once daily is strongly recommended as first-line pharmacological treatment 1
  • PEG produces a bowel movement typically within 1-3 days 2
  • PEG has shown significant increases in complete spontaneous bowel movements compared to placebo 1
  • Side effects may include abdominal distension, loose stool, flatulence, and nausea 1

Second-Line Options

• Add and titrate bisacodyl 10-15 mg daily to three times daily with a goal of one non-forced bowel movement every 1-2 days 1
• If constipation persists, consider:
  • Bisacodyl suppository (one rectally daily to twice daily) 1
  • Lactulose 30-60 mL two to four times daily 1
  • Magnesium hydroxide 30-60 mL daily to twice daily 1
  • Magnesium citrate 8 oz daily 1
  • Sorbitol 30 mL every 2 hours for 3 doses, then as needed 1

Special Considerations

Rule Out Underlying Causes

• Discontinue any non-essential constipating medications (antacids, anticholinergics, antidepressants, antispasmodics, phenothiazines, haloperidol, and antiemetics) 1
• Evaluate for impaction, especially if diarrhea accompanies constipation (overflow around impaction) 1
• Consider other treatable causes such as hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus 1

For Opioid-Induced Constipation

• If constipation is opioid-induced and unresponsive to standard laxatives, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (no more than once daily) 1
• Do not use methylnaltrexone in patients with postoperative ileus or mechanical bowel obstruction 1

For Persistent Constipation

• If gastroparesis is suspected, consider adding a prokinetic agent such as metoclopramide 10-20 mg orally four times daily 1
• For severe cases unresponsive to other treatments, newer agents like linaclotide may be considered 1, 3

Common Pitfalls to Avoid

• Increasing fluid intake alone has not been shown to significantly increase stool output in normal healthy volunteers unless they have low baseline fluid intake 4
• Adding stool softeners like docusate to stimulant laxatives like senna has not been shown to be necessary 1
• Wheat bran can exist as a finely ground powder that may decrease stool water content and harden stool in some patients 1
• Delaying treatment can lead to impaction requiring more invasive interventions 1

Most cases of constipation lasting 3 days will respond to the above measures, with PEG being the most evidence-supported pharmacological intervention 1, 2.