Treatment of refractory constipation

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A. Saline cathartics, such as magnesium-containing compounds and the phosphate enemas, work by an osmotic effect. Magnesium or phosphate overload may occur in renal insufficiency. Long-term use is not recommended. Magnesium hydroxide (1 -2 tbsp qd-bid) is most commonly used. In refractory cases, a half to 1 glassful of magnesium citrate is effective.

B. Lactulose is a hyperosmotic non-absorbable sugar that is often used for long-term management. Its advantages are nonsystemic absorption, minimal toxicity, and safety for prolonged use; 30 mL PO qd-bid. Sorbitol is significantly less expensive than lactulose; the 70% solution is taken as 30 mL qd-bid.

C. Lavage solutions (CoLyte, GoLYTELY) are used for refractory constipation. These agents contain a balanced electrolyte solution. A gallon can be administered in 4 hours to relieve an impaction. Eight to16 oz a day can be prescribed to prevent recurrence.

D. Prokinetic agents promote peristalsis in the colon. Cisapride (Propulsid) increases the frequency of bowel movements in chronically constipated patients at a dose of 10-20 mg qid [10 mg].

E. Combination therapy with an osmotic agent combined with a lavage solution and a prokinetic agent may be used for refractory constipation.

F. Enemas may relieve severe constipation. Low-volume tap water enemas or sodium phosphate (Fleet) enemas can be given once a week to help initiate a bowel movement.

G. Stool impaction. A combination of suppositories (glycerin or bisacodyl)

and enemas (phosphate) will soften the stool. Digital disimpaction may be necessary should these measures fail.

H. Surgery. When the above measures are not effective, surgery may be considered as a last resort. Surgical options include colectomy and ileostomy or an ileoanal pouch.

References: See page 195.

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Constipation Prescription

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