What is the emergency room management of constipation (bowel obstruction)?

From the Guidelines

Emergency room management of constipation should prioritize a stepwise approach, starting with a thorough assessment to rule out serious complications like bowel obstruction, and initial treatment with oral laxatives such as polyethylene glycol (PEG 3350) or magnesium citrate, as recommended by recent guidelines 1. The management of constipation in the emergency room setting requires careful consideration of the underlying causes and potential complications. A thorough assessment is essential to rule out serious conditions like bowel obstruction, which can have significant morbidity and mortality implications 1.

Key Considerations

• Initial treatment with oral laxatives, such as polyethylene glycol (PEG 3350) at a dose of 17g dissolved in 8 ounces of water once or twice daily, or magnesium citrate 200-300ml as a single dose, is recommended 1.
• For more severe impaction, an enema may be necessary, with options including sodium phosphate (Fleet) enema 118ml per rectum or mineral oil enema 100-250ml.
• Manual disimpaction might be required for severe cases, performed with appropriate analgesia and sedation.
• Intravenous fluids should be administered if the patient is dehydrated, and pain management with acetaminophen or, if necessary, low-dose opioid alternatives like tramadol may be appropriate.

Prevention and Self-Care

• Patients should be advised to increase dietary fiber to 25-30g daily, maintain adequate hydration with 6-8 glasses of water daily, and engage in regular physical activity after discharge 1.
• The underlying pathophysiology of constipation often involves slow colonic transit, inadequate fluid intake, or pelvic floor dysfunction, which these interventions help address.

Follow-Up and Referral

• Patients should follow up with primary care within 1-2 weeks, and those with warning signs like weight loss, rectal bleeding, or family history of colorectal cancer should be referred for further evaluation 1. It is essential to prioritize the patient's morbidity, mortality, and quality of life when managing constipation in the emergency room setting, and to base treatment decisions on the most recent and highest-quality evidence available 1.

From the FDA Drug Label

USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days Uses Relieves occasional constipation (irregularity) Generally causes bowel movement in 6 to 12 hours STOP USE AND ASK A DOCTOR IF • you have rectal bleeding or your nausea, bloating, cramping or abdominal pain gets worse. These may be signs of a serious condition. • you get diarrhea • you need to use a laxative for longer than 1 week

The management of constipation in the emergency room is not directly addressed in the provided drug labels. Key points to consider in emergency room management of constipation include:

• The provided drug labels do not mention emergency room management.
• The labels provide information on the use of polyethylene glycol and senna for relieving occasional constipation, but do not address emergency situations 2, 3.
• Potential signs of a serious condition that may require medical attention include rectal bleeding, worsening nausea, bloating, cramping, or abdominal pain 2.

From the Research

Emergency Room Management of Constipation

• Constipation is a common diagnosis in adults and children, with approximately 1.3 million ED visits occurring annually in the United States 4.
• The management of constipation in the emergency department (ED) involves excluding dangerous mimics or complications and discharging the patient with a bowel regimen tailored to the likely cause of their constipation 5.
• Polyethylene glycol (PEG) with or without electrolytes is an effective treatment for functional constipation and fecal impaction, and is considered a first-line treatment for functional constipation in the short and long-term 6.

Diagnosis and Assessment

• A comprehensive and person-centred assessment is fundamental to identifying constipation, and should include taking the patient's clinical history and discussing any lifestyle factors that may be causing or contributing to the condition 7.
• Constipation is a clinical diagnosis, and ideal management includes excluding dangerous mimics or complications 5.
• Abdominal radiographs (AXRs) are frequently obtained in the pediatric emergency department for diagnosis, but have poor reliability to rule out underlying pathology or prognostic ability to determine the degree of constipation 8.

Treatment and Management

• PEG with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability 6.
• Osmotic laxatives, such as PEG, are considered a first-line treatment for functional constipation in the short and long-term 6.
• A standardized evaluation and management algorithm for constipation can help decrease the use of AXRs and improve patient outcomes 8.
• Educational conferences and expanded electronic medical record interfaces can help standardize the approach to constipation management and discharge instructions for patients with constipation across all acuity levels 8.