II. Causes
- Attempt to identify cause
- Do not assume Narcotics are always the cause
III. Differential Diagnosis
IV. Management: Address each of four factors
- See Bowel Regimen in Chronic Narcotic Use
- Low intestinal solids
- Due to decreased Dietary Fiber
- Manage with Psyllium
- Avoid in Dehydration due to stool impaction risk
- Low stool water content
- Causes
- Dehydration
- Slow stool transit time
- Decreased intestinal water secretion
- Management
- Lactulose 30 ml PO every 8 hours until stool
- Sorbitol 30 ml PO q2-4 hours until stool
- Polyethylene Glycol (Miralax) 1 tablespoon (17 g) in 8 oz fluid orally daily
- Magnesium Hydroxide 30 to 60 ml orally at bedtime
- Glycerin suppositories
- Causes
- Low gastrointestinal motility
- Causes
- Non-ambulatory or bed-ridden patient
- Neurodegenerative disease
- Medications
- Management
- See Opioid Induced Constipation for Bowel Regimen in Chronic Narcotic Use
- Senna with Docusate 1 to 2 tabs orally 2 to 4 times daily
- Bisacodyl
- Prune juice
- Casanthranol
- Causes
- Decreased gastrointestinal lubrication
- Due to Dehydration
- Management
- Mineral Oil Enemas
- Glycerin suppositories
- Dioctyl Sodium sulfosuccinate
V. Management: Non-Cancer Comorbid Condition Palliative Measures and Precautions
- Cardiac disease (e.g. CHF, CAD, Transplant Rejection)
- AVOID high salt Laxatives (Magnesium Citrate, Magnesium Hydroxide, Sodium phosphate) if on signficant Diuretics
- AVOID Stimulant Laxatives (Senna, Bisacodyl)
- Prefer Osmotic Laxatives, such as Polyethylene Glycol (Miralax) or Lactulose
- Renal disease (e.g. Chronic Kidney Disease stage 4-5, Acute Renal Failure)
- AVOID high salt Laxatives (Magnesium Citrate, Magnesium Hydroxide, Sodium phosphate)
- Osmotic Laxatives, such as Polyethylene Glycol (Miralax), are safe, but require good hydration for efficacy
- Consider Stimulant Laxatives (Senna, Bisacodyl)
-
Liver disease (e.g. end-stage Cirrhosis)
- Osmotic Laxatives (esp. Lactulose) for Hepatic Encephalopathy or Ascites
- Stimulant Laxatives (e.g. senna)
- Neurologic disease (e.g. ALS, Dementia, Parkinsonism, stroke)
- Scheduled toileting
- Osmotic Laxatives (Polyethylene Glycol)
- Stimulant Laxatives (e.g. senna)
VI. Prevention
- See Bowel Regimen in Chronic Narcotic Use
- Prevention is much easier than treatment
- Administer prophylactic medications with Narcotics
- Gastrointestinal motility Stimulant Laxative and
- Stool Softener
- Example Agent: Pericolace