Effective Hospital Treatments For Constipation

Constipation is a common condition that can be treated in a variety of ways, depending on the patient's specific circumstances. Treatment of constipation in a hospitalised patient requires a tailored approach, as some therapeutic strategies may be more effective than others, depending on the cause of the constipation. For example, opioid-induced constipation is a common cause of constipation in hospitalised patients, and management of this condition should begin with ensuring adequate hydration and electrolyte balance and encouraging patient mobilisation. Other treatments for constipation may include laxatives, enemas, intestinal secretagogues, peripherally acting µ-opioid receptor antagonists, and manual disimpaction. Diet and lifestyle changes can also help reduce constipation symptoms.

Diet and lifestyle changes

Fluids

• Increasing water and juice intake to stay hydrated and maintain a healthy electrolyte balance.
• Consuming other liquids throughout the day.

Fibre

• Eating more fibre-rich foods to increase fibre intake.
• If dietary fibre intake is insufficient, adding a fibre supplement to your diet.

Exercise

• Engaging in regular physical exercise, such as walking, gardening, or house cleaning.
• Adults are recommended to get at least 150 minutes of moderate-intensity exercise weekly. This can be broken down into shorter periods of activity throughout the day.

Bowel Habits

• Allowing enough time for bowel movements each day and not ignoring the urge to go.
• Training yourself to have a bowel movement at the same time each day, such as 15 to 45 minutes after breakfast, to establish a routine.
• Using a footstool in front of the toilet to raise your legs and improve your bowel movement position.
• Sitting for 10 minutes after meals to promote healthy digestion and encourage bowel movements.

Medication Review

• Reviewing your current medications and supplements with your doctor to identify any that may be causing constipation.
• Discussing options to change the dose or switch to alternative medications that do not cause constipation.

These diet and lifestyle changes can help treat and prevent constipation. However, if symptoms persist or become severe, further medical advice and treatments may be necessary.

Laxatives

There are several types of laxatives, including bulk-forming laxatives, osmotics, stool softeners, lubricants, and stimulants. Bulk-forming laxatives add soluble fibre to the stool, making it bigger and softer, which stimulates the colon to contract and push out the stool. These are generally considered gentle and are recommended as the first option unless a healthcare provider suggests otherwise. Osmotics, also known as stool softeners, increase the water content in the stool, making it softer and easier to pass. Lubricants, such as mineral oil, create a slick layer on the intestine walls, preventing the stool from drying out. Lubricants are effective but are recommended for short-term use as prolonged use can interfere with the absorption of certain vitamins and medications. Stimulant laxatives, on the other hand, activate the nerves controlling the colon muscles, forcing the colon into motion to move the stool along.

While laxatives are a common treatment option, they are not always sufficient, especially in cases of opioid-induced constipation (OIC). In such cases, alternative treatments like PAMORAs may be more effective. Additionally, laxatives can have side effects such as bloating, diarrhoea, abdominal fullness, and abdominal cramping. They can also interact with certain medications, so it is important to consult a healthcare provider before taking them.

Enemas

There are several types of enemas, each with a specific purpose:

• Oil-retention enema: This type is for people with hardened stool. It softens the stool with a solution containing 90-120 ml.
• Return-flow enema (Harris flush): This is done for people with intestinal gas issues. A large volume of fluid is injected and then drawn out along with the gas.
• Cooling enema: This is used to lower body temperature in cases of extremely high fever.
• Cleansing enema: This procedure uses water to flush the colon and stimulate bowel movements.
• Barium enema: This type uses a liquid compound to highlight areas of the gastrointestinal tract, aiding in medical examinations.

The procedure for administering an enema involves filling an enema bag with a desired solution, usually a salt water mixture. The bag is connected to a tube that is lubricated and inserted into the rectum. The person receiving the enema lies on their side or stomach, hugging their knees to their chest to ensure the solution reaches the colon. The solution is then released into the rectum, stimulating the bowel and softening the stool.

While enemas can be effective in relieving constipation, they should be used with caution. Potential risks include rectal tearing, colon tissue damage, infection, and electrolyte disturbances. It is important to follow instructions carefully and consult a healthcare provider if there are any concerns or questions about the procedure.

Intestinal secretagogues

Constipation is often undetected in hospital settings, especially in patients who are elderly, institutionalised, on sedatives, or mechanically ventilated. Opioid-induced constipation is a common cause of constipation in hospitalised patients.

One treatment option for constipation in hospitals is intestinal secretagogues. These are useful and safe therapeutic alternatives for treating constipation-related syndromes. They act on enteric chloride channels or guanylate cyclase receptors to establish an electrolyte gradient in the bowel lumen, increasing luminal fluid content.

Secretagogues have been tested for the treatment of chronic constipation and constipation-predominant irritable bowel syndrome (IBS-C). They have been shown to be superior to placebo in increasing the number of complete spontaneous bowel movements per week, achieving three or more spontaneous bowel movements per week, and inducing spontaneous bowel movement after medication intake.

Linaclotide, lubiprostone, plecanatide, and tenapanor are some of the specific secretagogues that have been studied. Linaclotide was ranked first in efficacy based on abdominal pain and complete spontaneous bowel movements, while tenapanor was ranked first for decreasing bloating. However, the total numbers of adverse events were higher with linaclotide and plecanatide compared to placebo, and diarrhoea was a common side effect with all drugs except lubiprostone.

Surgery

Before considering surgery, a thorough diagnostic examination is conducted to evaluate if surgery is indeed required. This involves a careful review of the patient's medication and supplements, as these could be causing constipation. If they are, the patient's provider may change the dose, switch to another drug, or ask the patient to stop taking the supplement.

If surgery is indicated, there are several options available. For many years, subtotal colectomy with IRA was the treatment of choice. Nowadays, less invasive procedures like sacral nerve modulation (SNM) should be tried first. If this is unsuccessful, colectomy can still be considered, and it is estimated to improve constipation and quality of life in over half of patients. Other surgical procedures include segmental resections, which are a good option for isolated megasigmoid, sigmoidocele, or recurrent sigmoid volvulus. Stapled trans-anal rectal resection can also improve constipation symptoms and the inflammatory reaction in patients with outlet obstructive constipation.

It is important to note that surgical procedures are associated with potential risks and should be considered a last resort. Patients must be counselled that pain and/or bloating may persist even if surgery normalizes bowel frequency.

Frequently asked questions