Management of Constipation in Typhoid Fever
Constipation in typhoid fever should be managed conservatively with hydration, dietary modifications, and gentle laxatives if needed, while avoiding aggressive bowel stimulation that could precipitate intestinal perforation—a life-threatening complication occurring in 10-15% of typhoid cases. 1, 2
Critical Safety Considerations
The primary concern when managing constipation in typhoid fever is the risk of intestinal perforation, which typically occurs in the third week of illness but can happen as early as 24 hours into the disease course. 2 This complication carries mortality rates of 4.6-39% and requires immediate surgical intervention. 2
Antimotility agents (loperamide, codeine) are absolutely contraindicated in typhoid fever due to the risk of toxic megacolon and perforation. 3 These drugs should be avoided in any inflammatory diarrheal illness with fever. 3
Recommended Management Approach
First-Line Interventions
Increase oral fluid intake to maintain hydration and soften stool naturally, as adequate hydration is fundamental to managing constipation. 3
Encourage dietary modifications including increased fluid intake and, if the patient can tolerate oral intake, soft foods that promote regular bowel movements. 3
Maintain physical activity as tolerated, though this may be limited by the patient's febrile state and overall condition. 3
When Gentle Laxatives Are Needed
If constipation persists and is causing significant discomfort:
Polyethylene glycol (PEG) 3350 is the safest option, as it works by retaining water in the stool without stimulating bowel motility aggressively. 4 Administer 17g dissolved in 4-8 ounces of water daily. 4
Glycerin suppositories may be used for gentle local stimulation if oral agents are insufficient. 3
Docusate (stool softener) can be added to facilitate easier passage without aggressive stimulation. 3
Agents to Use With Extreme Caution
Bisacodyl and senna (stimulant laxatives) should generally be avoided in acute typhoid fever due to their mechanism of increasing bowel motility, which could theoretically increase perforation risk in inflamed bowel. 3 If absolutely necessary for severe constipation, use the lowest effective dose (bisacodyl 10mg once daily maximum). 3
Osmotic laxatives (lactulose, magnesium hydroxide) may be considered cautiously but should be avoided if there are any signs of bowel obstruction or severe abdominal pain. 3
Red Flags Requiring Immediate Evaluation
Stop all laxative therapy and obtain urgent surgical consultation if the patient develops: 2
- Severe or worsening abdominal pain
- Abdominal distension or rigidity
- Signs of peritonitis (rebound tenderness, guarding)
- Markedly elevated white blood cell count (>20,000)
- Hemodynamic instability
These findings suggest possible intestinal perforation, which requires immediate surgical intervention. 2, 5
Monitoring and Reassessment
Assess bowel movement frequency and character daily, with a goal of one non-forced bowel movement every 1-2 days. 3
Perform serial abdominal examinations to detect early signs of complications, particularly during the second and third weeks of illness when perforation risk is highest. 1, 2
Monitor for resolution of constipation as the typhoid fever responds to appropriate antibiotic therapy (azithromycin or ceftriaxone), as gastrointestinal symptoms typically improve with treatment of the underlying infection. 2, 6
Clinical Context
Constipation is a recognized presenting feature of typhoid fever, occurring alongside fever, abdominal pain, and other gastrointestinal symptoms. 1 The management priority is treating the underlying typhoid infection with appropriate antibiotics while providing gentle supportive care for constipation. 2, 6 Aggressive bowel management is unnecessary and potentially dangerous in this setting.