II. Causes

  1. Attempt to identify cause
  2. Do not assume Narcotics are always the cause

III. Differential Diagnosis

IV. Management: Address each of four factors

  1. See Bowel Regimen in Chronic Narcotic Use
  2. Low intestinal solids
    1. Due to decreased Dietary Fiber
    2. Manage with Psyllium
      1. Avoid in dehydration due to stool impaction risk
  3. Low stool water content
    1. Causes
      1. Dehydration
      2. Slow stool transit time
      3. Decreased intestinal water secretion
    2. Management
      1. Lactulose 30 ml PO every 8 hours until stool
      2. Sorbitol 30 ml PO q2-4 hours until stool
      3. Polyethylene glycol (Miralax) 1 tablespoon (17 g) in 8 oz fluid orally daily
      4. Magnesium Hydroxide 30 to 60 ml orally at bedtime
      5. Glycerin suppositories
  4. Low gastrointestinal motility
    1. Causes
      1. Non-ambulatory or bed-ridden patient
      2. Neurodegenerative disease
      3. Medications
        1. Morphine and other Narcotics
        2. Tricyclic Antidepressants
        3. Scopolamine
        4. Diphenhydramine (Benadryl)
        5. Vincristine
        6. Calcium Channel Blockers
        7. Iron Supplementation
        8. Calcium Supplementation
        9. Aluminum salts
    2. Management
      1. See Bowel Regimen in Chronic Narcotic Use
      2. Senna with Docusate 1 to 2 tabs orally 2 to 4 times daily
      3. Bisacodyl
      4. Prune juice
      5. Casanthranol
  5. Decreased gastrointestinal lubrication
    1. Due to dehydration
    2. Management
      1. Mineral Oil enemas
      2. Glycerin suppositories
      3. Dioctyl Sodium sulfosuccinate

V. Prevention

  1. See Bowel Regimen in Chronic Narcotic Use
  2. Prevention is much easier than treatment
  3. Administer prophylactic medications with Narcotics
    1. Gastrointestinal motility Stimulant Laxative and
    2. Stool Softener
  4. Example Agent: Pericolace

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