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PerttuArkkila

Obstipation in the Adult

Essentials

  • Rule out acute intestinal occlusion (total obstipation, pain, vomiting, visible peristalsis, swelling of the abdomen).
  • Refer patients with suspected organic disease for further investigations (pain, bloody stools, change in bowel habits, systemic symptoms, chronic obstipation in a young person).
  • Idenfity overflow diarrhoea as a symptom of obstipation.
  • Identify drugs as a cause of obstipation.
  • Start prophylactic medication for obstipation in patients who receive strong opioids for pain.
  • Give written instructions.

Definition

  • Decreased frequency and difficulty of defecation. Normally defecation occurs at 8-72 hour intervals.

Epidemiology

  • Obstipation occurs in 8-26% of healthy adults.
  • Up to 80% of immobilized elderly people have obstipation.

Aetiology

History

  • The definition of the patient's problem is most important.
    • Defecation frequency
    • Consistency of stools
    • Problems with the defecation process
    • Find out all drugs used by the patient.
    • Duration of the problem
    • Eating habits and physical activity
    • Does the patient have intermittently loose stools

Symptoms suggesting habitual obstipation

  • No other changes in bowel habits or general symptoms
  • A long history of obstipation

Symptoms suggesting organic disease

  • Increasing abdominal pain
  • Pain associated with defecation
  • Change in bowel habits
  • Melaena or anal haemorrhage
  • General symptoms (weight loss, fatigue, anaemia)
  • Family history of e.g. colon cancer

Investigations

  • Abdomen: inspection (scars), palpation
  • Touch per rectum, proctoscopy: haemorrhoids, fissures, faecal prop
  • General physical examination as necessary
  • If the symptoms suggest an organic disease the following investigations may be helpful:
    • Plain abdominal x-ray if intestinal obstruction or paralytic ileus is suspected
    • Rectoscopy
    • Colonoscopy, if an organic cause is suspected or if obstipation occurs as a new symptom in a person over 50 years of age.

Treatment

  • Treatment is indicated only if obstipation causes symptoms.

Temporary obstipation Interventions for Treating Constipation in Pregnancy

Chronic obstipation Lactulose Versus Polyethylene Glycol for Chronic Constipation, Laxatives for the Management of Constipation in Palliative Care Patients, Sacral Nerve Stimulation for Faecal Incontinence and Constipation in Adults, Management of Faecal Incontinence and Constipation in Adults with Central Neurological Diseases, Muopioid Antagonists for Opioidinduced Bowel Dysfunction in Cancer and in Palliative Care, Pharmacological Treatment for Antipsychotic-Related Constipation

  • Lifestyle changes
    • Correction of diet, adding fibre (target intake 20-35 g per day) and fluids (target intake 1.5-2 litres per day).
    • Increasing exercise
    • Adopting a regular defecation routine (e.g. every morning after breakfast)
  • Obstipation-inducing drugs are discontinued or their doses are reduced. The most common such drugs include opioids, diuretics, antipsychotic and anticholinergic drugs, as well as calcium and iron preparations.
  • Laxatives are used in a stepped manner, starting from bulk-forming laxatives, and adding, as necessary, a drug from another group at a time, depending on the cause and severity of obstipation.
    • Bulk-forming laxatives increase the volume of the stools.
    • Osmotic laxatives (e.g. lactulose, polyethylene glycol/macrogol)
      • Increase the water content of the stools and clean the bowel mechanically. They are very effective.
      • They may be administered through a nasogastric tube if necessary and are suitable for long-term use
      • Dose bags are available, but solutions intended for bowel cleansing can also be used.
    • Stimulant laxatives (bowel-stimulating laxatives)
      • Sodium picosulfate as a drug molecule is inactive, but it is activated by the colonic bacteria. Metabolism produces diphenols that increase colonic motility and have a local effect on the mucosa decreasing absorption of water. The drug both makes bulk of the faeces softer and increases bowel motility, hence alleviating obstipation. In elderly patients, long-term use is associated with a risk of decreased intestinal motility.
      • Bisacodyl and senna stimulate the bowel. Senna is also available as a combination with psyllium. These are suitable for temporary use or, for example, to boost the effect of a bulk-forming laxative.
    • Opioid antagonists
      • If sufficient response is not achieved with ordinary laxatives in the treatment of opioid-induced obstipation, treatment alternatives include either naloxone hydrochloride + opioid combination tablets, naloxegol or injectable methylnaltrexone bromide.
    • A mini-clysma relieves severe obstipation. If necessary, a large-volume water clysma can be used, but it involves a small risk of perforation.
  • Neurogenic obstipation
    • Obstipation caused by low-level injury should not be treated with bulk laxatives but with regular mini-clysma at 4-6 day intervals or by finger evacuation.
    • Obstipation caused by a higher injury can be treated by bowel training, finger evacuation and bulk laxatives.
  • Linaclotide or prucalopride can be used as symptomatic treatment for moderate or severe constipation-associated IBS in adults.
  • If there are problems with the defecation process, biofeedback training provided by physiotherapists may be beneficial.
  • Rectal lavage, nerve stimulation or surgical treatment may be used if the treatments mentioned above do not provide sufficient relief.

Evidence Summaries ⬆