Duphalac (Lactulose) Enema Protocol
For lactulose enema administration, mix 300 mL of lactulose solution with 700 mL of water or physiologic saline, administer via rectal balloon catheter, and retain for 30-60 minutes; this can be repeated every 4-6 hours if needed. 1
Specific Indications for Lactulose Enema
Lactulose enemas are specifically indicated when: 1
- Oral administration is not feasible due to impending coma or coma stage (particularly in hepatic encephalopathy)
- Risk of aspiration exists
- Endoscopic or intubation procedures physically interfere with oral dosing
Administration Protocol
Preparation and Delivery 1
- Solution composition: 300 mL lactulose + 700 mL water or physiologic saline
- Delivery method: Via rectal balloon catheter
- Retention time: 30-60 minutes
- Frequency: Every 4-6 hours as needed
- Important: If inadvertently evacuated too promptly, may repeat immediately
Pre-Administration Considerations 1
- Do NOT use cleansing enemas containing soap suds or other alkaline agents before lactulose enema administration
- Alkaline agents can interfere with lactulose's mechanism of action
Contraindications to Enema Use
Lactulose enemas should be avoided in patients with: 2
- Neutropenia (WBC < 0.5 cells/μL)
- Thrombocytopenia
- Paralytic ileus or intestinal obstruction
- Recent colorectal or gynecological surgery
- Recent anal or rectal trauma
- Severe colitis, inflammation, or abdominal infection
- Toxic megacolon
- Undiagnosed abdominal pain
- Recent pelvic radiotherapy
Expected Response Timeline 1
- Reversal of coma: May occur within 2 hours of first enema in some patients
- Transition to oral therapy: Should begin before discontinuing enema therapy entirely
- Once patient can tolerate oral medication, switch to oral lactulose at recommended doses
Alternative Enema Options for Constipation
When lactulose enema is not specifically indicated for hepatic encephalopathy, other enema options include: 2
- Sodium phosphate, saline, or tap water enemas - dilate bowel, stimulate peristalsis, and lubricate stool 2
- Warm oil retention enemas (cottonseed, olive oil) - lubricate and soften stool 2
- Bisacodyl enema - promotes intestinal motility 2
Important Limitations 2
- Use sodium phosphate enemas sparingly due to risk of electrolyte abnormalities
- Limit to maximum once daily in patients with renal dysfunction
- Avoid in neutropenic or thrombocytopenic patients
Oral Lactulose Dosing (For Reference)
When oral administration is appropriate: 1
- Adults: 30-45 mL (20-30 g) three to four times daily
- Infants: 2.5-10 mL daily in divided doses
- Children/adolescents: 40-90 mL total daily dose
- Goal: 2-3 soft stools daily