From the Guidelines
To treat moderate to large amounts of fecal content in the colon, particularly in the ascending and transverse portions, I recommend starting with an osmotic laxative such as polyethylene glycol (MiraLAX) at a dose of 17g mixed in 8 ounces of water once or twice daily for 3-7 days, as suggested by the most recent and highest quality study 1. This approach is based on the principle of drawing water into the intestines to soften stool and increase bowel motility, making evacuation easier. The absence of a rectal fecaloma and paucity of bowel gas in the pelvis suggests the impaction is primarily in the upper colon, which is why oral laxatives are the first-line approach rather than enemas. For faster relief, consider adding a stimulant laxative like bisacodyl (Dulcolax) 5-10mg orally or as a suppository, as recommended by 1 and 1. In more severe cases, a combination preparation like Golytely (4 liters) or Magnesium Citrate (10 ounces) may be necessary for complete evacuation. After initial clearance, maintain regular bowel movements with increased dietary fiber (25-30g daily), adequate hydration (at least 2 liters of water daily), and regular physical activity. For ongoing management, consider a maintenance dose of MiraLAX (17g daily) or docusate sodium (100mg twice daily), as these treatments have been shown to be effective in preventing recurrence of constipation 1. It's also important to note that suppositories and enemas may be considered in certain cases, such as when a digital rectal examination (DRE) identifies a full rectum or fecal impaction, as suggested by 1 and 1. However, the initial approach should prioritize oral laxatives due to their effectiveness and lower invasiveness. Overall, the goal is to achieve and maintain regular bowel movements while minimizing the risk of adverse effects and promoting quality of life.
From the Research
Treatment Options for Fecal Content in the Colon
To address the issue of moderate to large amounts of fecal content throughout the colon, particularly in the ascending and transverse portions, with a paucity of bowel gas in the pelvis and no rectal fecaloma, the following treatment options can be considered:
- Osmotic laxatives, such as polyethylene glycol (PEG) and lactulose, have been shown to be effective in treating constipation and fecal impaction 2, 3.
- PEG has been found to be more effective than lactulose in many instances, and should be considered as the laxative of choice unless there are contraindications 2, 4, 5.
- Non-pharmacological approaches to managing constipation, such as dietary changes and bowel habits, should be addressed before considering laxative use 2.
Comparison of Laxatives
Studies have compared the efficacy of PEG and lactulose in treating constipation and hepatic encephalopathy:
- A systematic review and meta-analysis found that PEG led to a significantly lower average HE Scoring Algorithm (HESA) Score at 24 hours, a higher proportion of patients with reduction of HESA Score by ≥1 grade at 24 hours, and a shorter time to resolution of HE compared to lactulose 5.
- A randomized clinical trial found that PEG led to more rapid resolution of hepatic encephalopathy than standard lactulose therapy 4.
Considerations for Treatment
When considering treatment options, it is essential to:
- Assess the patient's individual needs and contraindications for laxative use 2.
- Consider the potential benefits and risks of each treatment option, including the efficacy and safety of PEG and lactulose 3, 4, 5.
- Address non-pharmacological approaches to managing constipation before considering laxative use 2.