Information ⬇
Editors
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
- Lifestyle
- Lack of exercise
- Diet low in fibre
- Insufficient fluid intake
- Neglecting the natural feeling of need to defecate (army, school)
- Drugs
- Opioids
- Anticholinergic drugs (neuroleptics, antidepressants, drugs for urinary incontinence, drugs for Parkinson's disease)
- Stimulating laxatives in long-term use
- Sucralfate, antacids
- Diuretics
- Iron preparations
- Calcium-channel blockers and beta-blockers
- Metabolic and endocrinologic causes
- Neurological diseases
- Psychogenic causes
- Structural causes
- Functional causes
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.
- 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 ⬆