April 24, 2014

The Constipation Manifesto

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Scenario 1

Patient is on narcotics and you want to prevent constipation

Choice 1. Polyethylene glycol (PEG) 17g/1 glass per day. Up to 3 doses daily if needed

Choice 2. PEG + fecal inotrope/stimulant. Senna first choice

Choice 3. Docusate  + Senna

Docusate alone is probably not sufficient to prevent constipation in a patient on narcotics. The problem with narcotics is that they slow gut motility. Docusate works by breaking down fats, making stool soft/slick and also works as a weak osmotic laxative. This creates a soft stool that is still sitting in the colon. It’s like a fast car propped up on cinderblocks. If docusate is used in combination with a stimulant like senna, laxation improves significantly.

Warning: Bulking agents are often recommended as constipation prophylaxis for patients on narcotics. This may expand the diameter of the colonic lumen without moving anything though.

Scenario 2

Patient is on narcotics and is now constipated

Step 1. Manually disimpact if needed and place an enema in the ED.

Step 2. 2mg PO naloxone before ED discharge

Step 3. Disimpaction dose of PEG  (1.5g/kg/day or easy dosing 4 glasses per day). Take for 6 days or until soft stool passes, whichever comes first

Step 4. Maintenance PEG. (0.3-0.8g/kg/day or easy dosing 1 glass per day). Take for 2 weeks and slowly taper

Scenario 3

Need a soft stool because of a sore anus (fissure, hemorrhoids, abscess, etc)

Choice 1. Bulking agent like methylcellulose or psyllium. Must drink at least 1.5 liters of water per day, or the stool will become a colon shaped piece of concrete.

Choice 2. Docusate

Scenario 4

Constipated kids older than 1

1. I will often place a saline enema while the patient is in the ED.

2. Another option in the ED, especially for younger kids who may not be able to hold in an enema, is a glycerin suppository. Glycerin softens stool and makes the passageway slick, but more importantly, acts as a stimulant and increases intestinal propulsion. See The Suppository Conundrum for details on how to place an suppository.

3. Outpatient treatment: PEG disimpaction dose (1.5g/kg/day) for 6 days or until soft stool passes, followed by a maintenance dose of 0.3-0.8g/kg/day for two weeks followed by a slow taper

4. Lactulose also a laxative option

5. Stress a diet with lots of fiber and water

6. Don’t hold it in Kids should defecate when the urge strikes. Waiting may make the urge pass with the result being a harder, drier, more impacted stool. Then, like  an overdue baby, it won’t want to leave its happy home.  Kids will keep playing rather than going to the bathroom, and some have angst with pooping so they hold it in. We need to talk to our patients/parents about this.

What about mineral oil?
Mineral oil makes the stool slick and soft so it passes easier. In the studies and reviews I’ve read, the recurrent theme is that it shouldn’t be given in infants or long term use because of complications like aspiration, lipoid pneumonia and foreign body reaction in gut. The toxicity is increased if it’s given along with docusate. The risk/reward analysis does not favor mineral oil. Bottom line: there are better agents out there. If you really want to get mineral oil into the colon, give it as an enema.
 ************BONUS SECTION*********

Disimpaction Action

Below is Whit Fisher’s famous Disimpaction Action video. One thing I do differently than Whit is that I don’t tape my wrists (you’ll know what this means after watching the video). I realize the risk of ‘debris’ getting up the sleeve, but there is often need to remove the outer glove during or after the procedure. Also, I don’t want to unwind tape around my wrists using a glove smeared with fecal matter, which is inevitable in this procedure. Enjoy.

The Constipation Manifesto Cast of Characters

Joe Lex – Free Emergency Medicine Talks

Andy Sloas – PEM ED podcast

zdoggMD -zdoggMD.com

Graham Walker- The NNT, MD Calc, Emergency Medicine News

Mike Phillips

Aaron Wohl

 

Related posts:

Comments

  1. Hey -- was just listening to Larry Raney’s lecture on the effectiveness of non-opioid analgesics over at Joe Lex’s site and his last 2 minutes on Ketamine made me think of your podcast on constipation. How about pain dosed ketamine for narcotic bowel while you are taking them off dilaudid to get their bowels moving again? I’m sure there are no studies on this, but what do you think?

  2. Thank you for the very interesting episode. I now believe I know much more on the subject than I actually do. When I read “The Constipation Manifesto,” I also pooped in my drawers from laughing so hard: you might want to try giving patients a copy of the episode before giving other forms of treatment.

    The Constipation Manifesto. A suggested motto or two:

    You have the god-given right to be constipated!

    Forget communism: embrace constipation!

    Naw. Now that I think of it, none of this is funny…..

  3. Great episode RobO: one question.

    If you use the “Bomb” (bottle of mag citrate) as your disimpaction agent, is it reasonable to follow on with:

    Step 4. Maintenance PEG. (0.3-0.8g/kg/day or easy dosing 1 glass per day). Take for 2 weeks and slowly taper

    Also, during the step 4 phase can you go to increased fiber via a bulking agent like metamucil or is it wise to wait a bit so you don’t plug them up again?

    • Rob Orman says:

      I rarely use mag citrate, but I think a gentle landing with a week or two of PEG is not a bad idea whenever disimpaction is needed.

      As far as bulking agents, I’m not a big fan of them in the disimpaction phase. I generally use them if a soft fluffy stool is needed, such as with hemorrhoids, fissures, etc.

  4. Hi Rob. I love your podcast and had a question about oral narcan. Do we just use IV narcan orally, or is there a special oral form?

  5. Narcotic + docusate alone = All mush no push.

    Lovely blog post, thanks!

  6. Jim in Omaha says:

    As a person who works in a hospital (as an EMT) and lives with Chronic Intestinal Pseudo Obstruction; I was impressed with the variety of information on this topic. I would like to get in contact with Dr. Orman to share some of the tricks and tips I have discovered with the help of ER and other physicians. My strict daily treatment regimen includes laxatives (such as PEG -- along with Magnesium Glycinate), enemas, and exercise. Following it has allowed for running Half Marathons and other athletic events -- and has prevented the need for manual disempaction. Thanks for an excellent PODCAST that provides benefit to the doctor and patient…

    • Jim-
      By all means share your experience and knowledge!
      -Rob O

      • Jim in Omaha says:

        Here are my notes from the ERCAST (please check for accuracy) -- this helps to validate my regimen. I have a one page treatment/results summary that I share with my treating doctors -- not sure how to send that…

        CONSTIPATION MANIFESTO – FROM FEB 2012 PODCAST/ERCAST

        Chronic Narcotics (Naloxone works on GI receptors) – Dr. Graham Walker
        • Manual Dis-impaction, PO Narcan (2 mg), Miralax, Enema
        Fecal Impaction (Chipping away at giant block of ice) – Drs. Aaron Wohl & Rob Orman
        • ½ bottle of Mag Citrate in the ED
        • PEG (3-4 doses/day for 3-4 days or until soft stools)
        • 1-2 daily Fleet enemas for 2 consecutive days
        • Dis-impact (have soap suds ready after dis-impaction) while patient performing valsalvas
        • Patient in lateral lumbar puncture position
        • Insert tube far into colon and hold soap suds enema for 30 minutes
        • After stool removed: dis-impact dose Miralax (4 glasses/day for 6 days and glass/day several wks) & daily enemas
        • Most prefer daily enemas for dis-impaction dose (even though cause more fecal incontinence)
        Undifferentiated abdominal pain in kids – Dr. Andy Sloas
        • Ultrasound and KUB
        • Stool on left side – enemas (fleet, soap suds if unsuccessful, M&M) in ER
        • Sent home with recommendations for increasing water, Miralax, and Glycerin Suppositories
        • If note lots of stool on Right side – Bowel regimen for several days to clean out
        Constipated child – Dr. Rob Orman
        • Fleet enema or Glycerin suppository in ED
        • No evidence for or against rectal exam
        • Right colon stool column noted, even when doing daily BM– can be constipated even with daily bowel movement
        Constipation concept (bowel failure) – Preload, Inotrope, and Afterload – zdoggMD (“slightly funnier than placebo”)
        • Lactulose (increase stool volume – could become “concrete”); Inotropic agents (Dulcolax, Mineral oil, enemas) good
        • BOMB: Mag Citrate + Glycerin + Water in an enema (used at Stanford) -- very effective
        Obstruction (when to admit to hospital): failed output, treatment not working/can’t do enemas – Dr. Mike Phillips
        • Rectal exam – digital; Lots of stool – dis-impact (pick it out)
        • Higher impaction – Gastrograffin enema (therapeutic, hypertonic) 80% effective; Determine if need enemas/oral
        • Need fluid to get to the cecum
        • Mega Colon: dilated 12 cm cecum, or descending (unusual in descending); cecum > 12 cm in x-ray: be in hospital
        Manual dis-impaction: Sticking fingers to remove stool – Dr. Mike Phillips
        • Double glove; assess rectum – assess hardness of stool (Mineral oil enema to soften); try to reach stool
        • Hook and pull it down with 2 or 3 fingers; can’t reach – patient does bear-down maneuver
        • Can have little bit of blood when impaction removed (compression ulcer can cause bleeding after disimpact)
        • Fleet enema – mechanism: irritates mucosa; but with lower volume
        • Soap suds enema – mechanism: castile soap/water decreases surface tension; Slide enema tube as far as it will go
        • Place in head down position for 30 minutes after soap suds enema, than evacuate
        • Not much enema data – type used in ER is based on where doctors trained and were told to use
        • Return flow enema effective; but messy
        Colonic Pseudo Obstruction (blank stare in the ER) – Ogilvie Syndrome (mostly inpatient) – Dr. Mike Phillips
        • Right colon dilated; Left colon looks obstructed
        • Diminished motility (Ortho belly, Nephro belly, Cardio belly)
        • Signs and Symptoms: Gas filled colon (mostly R side) on x-ray…Identify underlying condition
        • Increase mobility (alternate prone and supine positions)
        • Encourage moving around
        • Laxatives needed, good if passing gas and feeling less distended
        • Clear liquid diet advised
        • Avoid lactulose (gas producing)
        Narcotic bowel syndrome (more narcotics the worse their pain) – Dr. Mike Phillips
        • Anti-spasmodic medications decrease motility (more abdominal pain)
        • Benzodiazepines might help for acute flair
        • Explain constipation is problem w/narcotics – bulking agents bad (stool not moving and enlarging, so might worsen)
        • Colace is placebo; PEG or saline laxative is good – follow with stimulant laxative
        • Might need detox
        Constipation risk or constipated – nothing working: Dr. Mike Phillips
        • PEG or Miralax best way to start (1-2 doses/day suggested; but can go up to 3-4 doses/day without concern)
        • Stimulant laxative (Dulcolax or Senna) next part of regimen
        • Add Mag Citrate (1 bottle) – can cause vomiting in about 10% of patients
        • Constipation can cause vomiting (stomach vs colon) without obstructive pattern
        • Top 3 Common patient complaints: discomfort, bloating, nausea + rectal bleeding, vomiting
        • Miralax (no issue w/lack of electrolytes, w/typical dose 1-2 times/day). Electrolyte-containing PEG good for elderly
        • Senna very effective (not much risk of habituation – helps contractility; but leopard skin look in colonoscopy)
        • Tegaserod (Zelnorm) no longer available
        • Amitiza very costly; nausea/vomiting is common side effect – not a miracle drug
        • Misoprostol sometimes used (now proton pump inhibitors widely used) – diarrhea common side effect
        History of Constipation – Dr.. Joe Lex

      • Jim in Omaha says:

        Not sure how many get a colonoscopy done without any sedation or medication; but that was my choice when it was performed in 2012 -- having had a similar (without medication or sedation in 2008), and one done in 2003 (with minimal pain medication via IV). This allowed me to converse with the GI Doctor (in real time), and quickly return to my daily colon regimen. Following is an article submitted for publication to the AGMD (Association of Gastrointestinal Motility Disorders) website -- with minor editing to reflect the PODCAST:

        With my history of slow transit constipation, I had to do a 2 1/2 -- day prep. As of Christmas Day 2012 (when I had to drink a bottle of Magnesium Citrate between 6:00 and 7:00 PM) -- I could consume no solid food, until my procedure (which started at 11:30 AM) was completed December 27th. The prep solution and dosing schedule (compared to 2008) had also changed. This time, I had to consume 4 liters of a product called Tri Lyle. Rather than drink my 8 ounces every 10 minutes, until the jug was empty; I had to spilt the dose. I would drink 8 ounces every 10 minutes (the day before my procedure) -- until 1/2 of the 4 liters was consumed. The remaining 2 liters would be consumed the morning of my colonoscopy. The taste of the new product wasn’t much better than what I had to drink the last time I was scoped (in 2008). I did pick up some good ideas that made it easier to handle -- something I want to share with your listeners. Note that if my advice conflicts with what you were told by your doctor, be sure to follow your doctor’s instructions.

        • The prep should be chilled to make it more palatable. If the prep comes with flavoring, note that the taste might not be much improved; but it will certainly help.
        • When you drink the prep, don’t sip it. Drink it down as quickly as possible (without upsetting your stomach).
        • Eat hard candies (which according to my instructions, still complied with my “liquid diet” restrictions) between each glass or every other glass. I consumed Watermelon, Pineapple, and Orange Life Savers.
        • Use a diversion to help track the 10-minute interval, while still keeping your mind off the nasty stuff you had to drink. I used the 25th anniversary celebration of Les Miserables (total of just under 3 hours), which I had found on You Tube and placed on my IPAD. The musical segments were short and quite motivating. Also, the IPAD includes a clock feature.
        • Track each time interval -- so that you know when each prep dose was consumed. It helps to motivate you, when you see progress being made -- or for times when you have to break away for the bathroom. It keeps you on track. For example, I started my first day’s doses at 6:00 PM and finished at 7:30. I started my second round at 5:00 AM on December 27th
        • Check with your doctor before making any additions or deletions to your prep. I was able to add Miralax and some extra tap water enemas (to help push out the stool after drinking the Magnesium Citrate) -- important with my slow transit concerns. Those steps also fit in with my usual regimen (see the 2008 Forums for details).
        • Follow the prep instructions, even though it might not be pleasant. One objective of a colonoscopy is to help your endoscopist discover abnormalities, before they cause health issues. If your colon is not clean enough, polyps and other present and future concerns can be missed. At the very least, if not cleaned out sufficiently, you might have to reschedule and do it right…

        • I hope you will consider placing these in your PODCAST site. I am sure that many of your patients have had to (or will) undergo this procedure. Getting it done without sedation or medication -- while not for everyone -- allowed me to learn more about this part of my anatomy, and talk to the endoscopist (about my concerns) in “real time.”

      • Jim in Omaha says:

        My final article tonight -- this summarizes my diagnosis and how I manage it daily, weekends, before races, when traveling, and on vacation -- thanks for allowing me to share the information…

        I have a chronic condition (diagnosed in 2004) that results in periodic intestinal pseudo obstructions. I was also diagnosed (in 2003) with slow colon motility, caused by a large colon and narrowed sigmoid colon. This results in my following a very strict self-imposed daily regimen (laxatives, exercise, eating, enemas, and evacuate) -- lest I end up having to visit the ED -- to get disimpacted (something neither I nor hospital staff would appreciate, and has not been done). I visit my GI Specialist about every 6 months to keep both of us aware of what is going on with my condition (my treatment regimen and successes) -- a condition caused by intestinal nerves and muscles not working in perfect sync (partly the result of sigmoid volvulus surgery in 1981, which left me with 2 feet less of intestine and a large abdominal scar -- near where the colostomy stoma used to be) -- which could ultimately result in loss of my colon.

        By working at a hospital, I have the opportunity to speak openly (but discretely), to numerous medical professionals, about my condition. They have all commented favorably about my diligence, and concurred with my approach -- an approach that resulted in my running my first half marathon in 2010; allows me to run in other competitive 5K, 10K, and Half Marathon races; and keeps my abdominal bloating – much of the time -- under control.

        My typical weekday morning regimen includes:

        1) 17 G dose of Miralax (PEG), along with a 400 mg Magnesium Glycinate tablet (something suggested, by an ER Physician, as a healthy stool softener). If I sense a pseudo obstruction (discomfort at my 1981 surgery stoma site and extreme distention), the Magnesium Glycinate is replaced by a bottle of Magnesium Citrate.
        2) A minimum of 30 minutes of cardiovascular exercise (jogging in place at home, or on a treadmill – if on vacation).
        3) A breakfast (usually a dish of microwaved frozen peaches served over a microwaved frozen pancake, and 2 turkey/pork microwaved meatballs) -- helps the gastrocolic reflex kick in.
        4) Administration of an enema (usually a Fleet enema from which I dumped much of the solution and replaced it with mostly tap water), followed by lying on my stomach (in a knee-elbow-butt in the air position), to propel the gas in my intestines.
        5) Expel the fecal contents.

        I do another cardiovascular workout in the evening – starting with a 17 g dose of Miralax, 30 minutes minimum of jogging in place, another dilute Fleet enema, and evacuate the stool.

        The regimen changes on the weekend, when I have more time to spend in the bathroom. I start out with 7.5-10 ounces of Magnesium Citrate or a 400 mg Magnesium Glycinate tablet, and a 17 g dose of Miralax in Water or Starbucks Frappuccino. After waiting about 1 -- 1 1/2 hours for that to kick in (during which time I normally do my 30 minutes minimum of cardiovascular exercise), I administer a series of larger volume enemas – usually starting with a 2000-2500 ml warm tap water enema, to which I have added some Fleet solution or table salt, and then expelled the fecal contents; following that with a cooler 1500-2000 ml tap water enema, to which I have added a packet of Castile soap, and then expelled the fecal contents; and following that with a 1500-2000 ml cool tap water enema, to which I have added 2 TBSP of sea salt, Fleet solution, or several packets of salt/baking soda (several packets of the Neal Med sinus irrigation medication) -- using a 2500 ml enema bag (with contains a retention nozzle and inflator – my Gastroenterologist is aware of my process). The retention nozzle can be inserted (after all the enemas have been excelled), as a way to help expel any (or most of the remaining) liquid fecal contents.

        Both my GI doctor and primary care doctor are aware of, and have fully supported these actions. Their response has been that these actions (including the larger volume enemas) are safer and more effective than multiple oral medications (other than the Miralax and Magnesium products), and have prevented the need for hospital intervention (and disimpaction) since my surgery in 1981. The final actions are more exercising and then eating (unlike the weekday, when I eat breakfast before administering the enema). This regimen continues to be so effective that my doctors don’t generally note signs (during my scheduled appointments) that I have this condition, even though they and I concur that I have the symptoms and the diagnosis.

        My regimen helps me to prepare for competitive 5K and 10K races, as it did for my first Half Marathon in 2010. I plan to perform a colon cleanout (similar to my weekend regimen) 2 days out (done on Friday evening for a Sunday event) from the race. The day before the race, I administer a 1500 mL bag enema, filled with tap water, into which I have added some Fleet solution. I try to eat low fat and low residue high protein food until the race (so that I have minimal stool in my colon). The day of the race, I administer a very dilute Fleet enema (the small bottle), to help expel any gas that would result in bloating during the race. I drink several glasses of water up to about 2 hours before the race (which reduces my Porta Potty trips at the race site). This process has prevented any bloating (gas filled colon) or diarrhea issues during or after the race. Unlike many competitive runners (certainly much younger than I), who take Imodium to control their peristalsis and bloating, I prefer and have found it advantageous to do a colon cleanout to prevent the same concerns. After the race, my GI system is back to normal. My GI Specialist agrees.

        Air travel or long distance by car creates challenges, among those prone to constipation due to slow motility. My approach is similar to that done on weekends. Also, the same equipment used for my weekend cleanout is packed in my luggage – in case being away from my usual food or bathroom facilities results in a pseudo obstruction.

        The whole process seems daunting and time-consuming; but it has resulted in not needing any hospital (ER or surgery) intervention – including manual disimpactions – since my 2 abdominal surgeries in 1981. Lest you think that I am a patient self-treating to his detriment; the information I am sharing with you has also been shared with my Gastroenterologist, Family Doctor (Internal Medicine Specialist) countless doctors, nurses, and pre-hospital care professionals with whom I interact at the hospital that provides my employment. The bottom line is that what I do to keep my colon functioning semi-normal, has allowed me to keep the remainder of my colon – that seems like a small price to pay…I am always open to ideas for how to manage my Chronic Intestinal Pseudo Obstruction. The ERCAST helped to validate my treatment regimen. It is hoped that the information I have conveyed, will suggest some treatment modalities when you (as ER physicians) are faced with patients presenting in the ER with chronic pseudo obstructions.

      • James Lewandowski says:

        Much like what you’ve stated in your ERCAST, regarding dealing with constipation -- when I cope with Colonic Pseudo Obstruction, there’s lots of room for style:

        Midweek (usually Wednesday, or Thursday) -- when I’m starting to feel more bloated and sluggish from several days worth of food -- I’ll administer a 1500 mL enema (with some Fleet solution and/or a bit of castile soap added) in the morning (just as I did today).

        Holidays and parties often mean more food and a greater likelihood of constipation, so I’ll “step up my game” with a larger single dose of Miralax (17g+), more exercise, and/or an additional enema.

        I find enemas more predictable than suppositories. When I was first diagnosed with colonic pseudo obstruction in 2004, my Primary Care Doctor recommended Dulcolax suppositories twice a day for 2 weeks. The cramping was unbearable and I discontinued those. I discovered a tap water enema worked better -- faster acting and able to sooner get back to normal.

        On occasion, I have consumed 2 bottes of Magnesium Citrate -- if the first was not effective (at the recommendation of my Gastroenterologist). Citrate is my Magnesium of choice when I have an episode of Pseudo Obstruction (noted by pressure at my stoma site and bloating not relieved by exercise or my daily treatments) .

        I have spoken to my GI Specialist about Colon Hydrotherapy, He feels that my enema therapy is cheaper, safer, more convenient (done at home), and just as effective.
        When I saw my GI Specialist in 2013, he suggested a Milk and Molasses enema as an alternative to the more conventional type -- Sounds like it’s an effective treatment for more than just kids.

        My regimen before my 5K run this Sunday (Holiday Hustle); won’t be quite as aggressive as before my Half Marathon in 2010. It will however, encompass the 5 elements of my program (Laxative, Exercise, Eat, Enema, and Evacuate) -- perhaps in a slightly different order than my usual weekday or weekend regimen.

        The treatment noted above is how I cope with a condition that will be life-long. It is hoped my experiences and tips will suggest options, as you treat patients similar to me.

      • Jim in Omaha says:

        Can you change last entry to “Jim in Omaha” says…Thanks

Trackbacks

  1. [...] CAST who gives us the low down on a down low topic. Yes that right we all get excited about the constipated patient,  and the thought of having to do a manual disempaction. However this podcast brings [...]

  2. [...] untested Cocktail, I have adopted one that I was introduced to through #FOAMed on ERCast’s Constipation Manifesto podcast.  Thanks to Rob Orman @emergencypdx for his excellent podcast and Dr. Aaron Wall for [...]

  3. [...] untested Cocktail, I have adopted one that I was introduced to through #FOAMed on ERCast’s Constipation Manifesto podcast.  Thanks to Rob Orman for his excellent podcast and Dr. Aaron Wall for sharing his [...]

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