What is the recommended treatment for constipation lasting over 2 days?

Treatment for Constipation Lasting Over 2 Days

For constipation lasting over 2 days, initial treatment should include increasing fluid intake, dietary fiber, physical activity when appropriate, and starting with a stimulating laxative such as bisacodyl 10-15 mg daily to three times daily with a goal of one non-forced bowel movement every 1-2 days. 1

First-Line Interventions

• Increase fluid intake and physical activity as tolerated 1
• Increase dietary fiber if patient has adequate fluid intake and physical activity 1
• Discontinue any non-essential constipating medications (antacids, anticholinergics, antiemetics) 1
• Rule out impaction, especially if diarrhea accompanies constipation (overflow around impaction) 1
• Rule out obstruction through physical examination and consider abdominal x-ray if symptoms are severe 1
• Assess for other treatable causes (hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus) 1

Medication Management Algorithm

Step 1: Initial Treatment

• Add and titrate bisacodyl 10–15 mg daily to TID with a goal of 1 non-forced bowel movement every 1–2 days 1
• Consider polyethylene glycol (PEG) 17g mixed in 8 ounces of liquid once daily, which has shown superior efficacy compared to placebo with an increase in complete spontaneous bowel movements per week 1

Step 2: If Constipation Persists

• Administer glycerine suppository or mineral oil retention enema 1
• Consider bisacodyl suppository (one rectally daily to BID) 1
• Add other laxatives such as:
  • Polyethylene glycol (1 capful/8 oz water BID) 1
  • Lactulose, 30–60 mL BID-QID 1
  • Sorbitol, 30 mL every 2 hours × 3, then as needed 1
  • Magnesium hydroxide, 30–60 mL daily-BID 1
  • Magnesium citrate, 8 oz daily 1

Step 3: For Severe or Refractory Constipation

• If impaction is present, perform manual disimpaction following pre-medication with analgesic ± anxiolytic 1
• For opioid-induced constipation, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (no more than once daily) 1
• Consider tap water enema until clear for severe cases 1
• If gastroparesis is suspected, add a prokinetic agent such as metoclopramide 10–20 mg PO QID 1

Important Considerations and Cautions

• Bulk-forming agents like psyllium or methylcellulose should be taken with adequate fluid to prevent choking or esophageal obstruction 2, 3
• Seek immediate medical attention if constipation is accompanied by rectal bleeding, severe abdominal pain, or failure to have a bowel movement despite treatment 2, 3
• Constipation lasting more than 7 days despite treatment requires medical evaluation 2, 3
• The evidence for fiber supplementation is strongest for psyllium, though even this evidence is of low quality 1, 4
• For chronic constipation, PEG has demonstrated moderate certainty of evidence for efficacy and should be considered over other options 1, 5
• Stimulant laxatives should generally be reserved for as-needed use rather than long-term daily use 4

Special Situations

• For patients with opioid-induced constipation, peripherally acting μ-opioid receptor antagonists like methylnaltrexone can provide relief while maintaining pain control 1
• For patients with constipation-predominant irritable bowel syndrome, dietary monitoring and fiber therapy may be most beneficial 4
• For patients with pelvic floor dysfunction resulting in dyssynergic defecation, biofeedback therapy may be most appropriate 4

Remember that if constipation persists despite these interventions, further evaluation for underlying causes is warranted, especially if accompanied by warning signs such as rectal bleeding, weight loss, or significant change in bowel habits 2, 6.