February 10th, 2013
What is your best treatment for “refractory” constipation?
In treating patients with constipation, we have several options for first-line agents: bulking agents/fiber, osmotic laxatives, or stimulant laxatives. When a patient has a suboptimal result, we commonly add or move to another class of laxative agents. Fortunately, most patients respond to these interventions, but we all have patients whose condition is “refractory” to these commonly used treatments. In the last few years, newer agents to manage constipation such as lubiprostone and linaclotide have also become available. But how best to manage these patients remains unclear, at least to me. So, here’s what I would like to know from you.
What do you use as first-line treatment in a patient with constipation?
What is your add-on treatment when your first-line treatment fails?
Do you use the newer agents, and if so, when? Do you use them to substitute for another agent or add them on?
In what circumstances do you consider surgery to treat constipation?
If a colonoscopy is negative, do you routinely use other diagnostic tests in a patient with constipation?
Looking forward to hearing your management strategies.
24 Responses to “What is your best treatment for “refractory” constipation?”
M. Brian Fennerty, MD
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NEJM Journal Watch Gastroenterology
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For adult males, use a fiber foods chart to demonstrate how to consume 35 grams of fiber daily (from foods, not supplements). Women should consume 25 grams daily. Children and adolescents, 10 – 15 grams daily. Also, 8 oz of water with breakfast, lunch and dinner is a minimum amount of water each day.
If constipation persists then ask the patient to drink 470 ml of Magnesium Citrate (this entire volume should be consumed within 15 minutes). One hour after drinking the Mag Citrate, have the patient use any Sodium Phosphate enema (Fleets). This approach is not likely to work in patients with mega colon.
One of our patients claimed that none of the suppositories she tried worked, but what worked for her was intake of chia seeds, apple cider vinegar, and tea made from senna leaves.
Great post and very informative
You might need a stool softener, not a laxative. I had oral surgery and was prescribed amoxicillin (antibiotic) and endocet (pain reliever containing acetaminophen and oxycodone). In the patient prescription information for endocet it lists constipation as a possible side effect, and goes on to say “To prevent constipation, eat a diet adequate in fiber, drink plenty of water, and exercise.” I had not had side effects from medication before that I can remember, and unfortunately, I did not read all of this prior to using this medication. After the surgery I became severely constipated.
I had not eaten anything for several days, so when my bowl movements stopped I did not notice. Rarely in my life have I been constipated. Once I started eating again, I became uncomfortable within a few days and realized that I was constipated. I tried prune juice, laxatives such as Ex-Lax, Phillips Milk of Magnesia, SenokotXtra, and a self-administered rectal suppository. Nothing worked. Days were going by and I was becoming extremely uncomfortable and was very close to going to the emergency room for a rectal water enema. I decided to call my doctor (general practitioner) first to ask his advice, but he was on vacation so I spoke to another doctor in the office. I related the story above. Although I was seeking advice on what over the counter medication I should take, I was advised instead to go to the emergency room and have an x-ray because I might have a tumor. Of course, I thought that was ridiculous. I did not suddenly develop a tumor. Although I had not read it, it seemed to me my problem was the result of taking pills for several days while not eating much of anything. Then I called a pharmacist, who then recommended medications that I had already taken. No new ideas there either. Finally I called the dental surgeon who operated on me. This seemed at the time to be an odd question for him, but I was getting desperate.
He immediately said I needed a stool softener and recommended Colace. He said such problems were common in hospitals and this is what patients were often given. I bought it, took it, went for a long walk around the neighborhood and periodically walked around the perimeter of the backyard for 15 minutes at a time, and in 12-18 hours began to have relief.