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BOWEL REGIMEN FOR CONSTIPATION

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As healthcare providers, we prescribe bowel regimens almost daily in the hospital. Have you ever considered the best recommendations? 

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1. First-line pharmacologic treatments for constipation are bulk-forming laxatives, such as Psyllium. These laxatives are indigestible and not systemically absorbed. They work by absorbing and retaining water in the stool, which helps increase stool bulk and transit time through the intestines. There are soluble fibers and insoluble fibers. 

 

  • Soluble Fiber: Sources include nuts, beans, oats, plant fibers (e.g., Benefiber), and psyllium (e.g., Metamucil). Once ingested, soluble fiber absorbs water and forms a gel-like substance that traps food, glucose, cholesterol, and fats in the stomach and carries them through the digestive tract. This process softens hard stools.

 

  • Insoluble Fiber: Found in whole grains and leafy greens, insoluble fiber helps promote regular bowel movements. It draws water into the intestinal lumen, increasing peristalsis and maintaining bowel regularity.

 

  • One situation to avoid bulk-forming laxatives is if fecal impaction is suspected.

 

2. If the patient is still constipated, consider osmotic laxatives. Osmotic laxatives pull fluid into the lumen. They are a second-line treatment, such as polyethylene glycol (PEG), also called Miralax or Lactulose. They draw water into the intestinal lumen by osmosis, helping to soften stool and speed intestinal transit (increase peristalsis). 

 

  • Polyethylene glycol is the most studied osmotic laxative. It is superior to lactulose in improving stool consistency and frequency. ​

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  • Milk of Magnesia is also an excellent second-line agent but is avoided in patients with renal disease due to the risk of hypermagnesemia due to the accumulation of magnesium. 

3. Is the patient still constipated? Consider stimulant laxatives. 

 

  • If symptoms persist, add a short course of a stimulant laxative, such as bisacodyl or senna. These drugs increase colonic contractions but do not affect stool consistency. 


 

4. FACT: Osmotic laxatives are preferred over stimulant laxatives for long-term use. 

 

5. FACT: Stool softeners, like Docusate, are not used as initial therapy since the benefit has not been proven. There are reports that docusate was no better than placebo in diminishing symptoms of constipation. It is a misconception that docusate softens hard stool in constipation. The totality of clinical evidence shows that docusate is not different from placebo. 

 

6. Is the patient still constipated? Try some medications from below, such as suppositories and enemas. 

 

  • A suppository is a small tube-shaped object placed in the rectum to deliver medicine.

 

  • The suppository melts at body temperature and releases the medicine. It is only useful when stool is present in the rectal vault. 

 

  • An enema is fluid gently pumped into the rectum to help pass stool. It may be used when other treatments don't work.

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  • Sodium phosphate (Fleet enemas) is used for bowel cleansing before specific procedures. Still, they are only limitedly used for constipation because of potential adverse effects such as hyperphosphatemia, hypocalcemia, and the rarer but more severe complication of acute phosphate nephropathy. 

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