What is the treatment for severe constipation with fecal impaction?

From the Guidelines

Severe fecal loading requires immediate treatment with suppositories and enemas as the first-line therapy, especially when a digital rectal examination (DRE) identifies a full rectum or fecal impaction. The management of severe fecal loading involves a multi-step approach, focusing initially on disimpaction using oral or rectal medications. According to the most recent and highest quality study available 1, the use of suppositories and enemas is crucial in the initial management of severe fecal loading.

Initial Management

For rectal disimpaction, options include:

• Suppositories containing glycerine, bisacodyl, or CO2-releasing compounds, which act as stool softeners and stimulants for rectal motility 1.
• Enemas, such as hyperosmotic saline, which increase water content and stimulate peristalsis to aid in expulsion 1.
• Phosphate enemas, which are effective for disimpaction and can be used in combination with other treatments 1.

Maintenance Therapy

After disimpaction, maintenance therapy is essential to prevent recurrence. This may include:

• Daily use of osmotic laxatives like polyethylene glycol (PEG 3350) or lactulose 1.
• Stimulant laxatives such as bisacodyl or senna for resistant cases 1.
• Lifestyle modifications, including increased fluid intake, dietary fiber, regular physical activity, and establishing a consistent bowel routine 1.

Severe Cases

Severe cases of fecal loading may require hospitalization for manual disimpaction under sedation or more aggressive bowel cleansing regimens supervised by healthcare professionals 1. In some instances, a defunctioning loop ileostomy may be considered before proceeding with total colectomy, emphasizing the importance of a tailored approach to each patient's condition 1.

The goal of treatment is to soften stool, increase intestinal motility, and restore normal bowel habits, thereby improving the patient's quality of life and reducing morbidity and mortality associated with severe fecal loading.

From the FDA Drug Label

USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days The treatment for severe fecal loading is not directly addressed in the provided drug label. However, polyethylene glycol (PO) is indicated for relieving occasional constipation.

• The drug label does not provide information on the treatment of severe fecal loading specifically.
• Polyethylene glycol (PO) may be used to relieve constipation, but its effectiveness in treating severe fecal loading is not explicitly stated 2.

From the Research

Treatment Options for Severe Fecal Loading and Constipation

• The treatment of fecal impaction should start with mineral oil or warm water enemas 3.
• For constipation, lifestyle modifications such as scheduled toileting after meals, increased fluid intake, and increased dietary fiber intake are recommended as the initial treatment 3.
• Additional fiber intake in the form of polycarbophil, methylcellulose, or psyllium may improve symptoms, but should be slowly increased over several weeks to decrease adverse effects 3.
• Osmotic laxatives like polyethylene glycol are effective for the treatment of functional constipation and fecal impaction, and are considered a first-line treatment 4, 5.
• Stimulant laxatives like bisacodyl can also be used to treat constipation, and have been shown to be effective in increasing the number of spontaneous bowel movements per week 6.

Comparison of Treatment Options

• Polyethylene glycol has been shown to be more effective than lactulose in treating chronic constipation, with better outcomes in terms of stool frequency, stool form, and relief of abdominal pain 5.
• Bisacodyl has been shown to be similar in efficacy to other laxatives such as prucalopride, lubiprostone, and linaclotide, and may be superior in terms of increasing the number of spontaneous bowel movements per week 6.
• The use of peripherally acting mu-opioid antagonists may be effective for opioid-induced constipation, but are expensive 3, 7.

Management of Chronic Constipation

• The management of chronic constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed by intestinal secretagogues and/or prokinetic agents if necessary 7.
• Anorectal tests and colonic transit studies may be necessary to evaluate for defecatory disorders and colonic dysmotility in patients who do not respond to over-the-counter agents 7.