Constipation is the symptom and is associated with primary & Secondary causes. Constipation is defined as occurrence of >3 episodes of bowel movements. the Rome III criteria defines the objective classification and bristol stool chart helps in assessing the type of stools passed. Management of constipation deals with early assess, treating the cause, adjuvant management, Pharmacological Management (laxatives, suppositories & enemas) and following constipation prevention bundle.
Why invest into infodemic management in health emergencies
Constipation in hospitalized patients
1. CONSTIPATION IN HOSPITALIZED
PATIENTS: ENSURING BOWEL
EVACUATION
Dr. Prabhjot Saini MSN PhD
Professor & Principal
Shaheed Kartar Singh Sarabha
College Of Nursing, Sarabha, Ludhiana,
Punjab.
3. Key Points
Constipation is a common condition among hospitalized patients and
functional constipation is the most common cause
Constipation can be a primary disorder or can be secondary to a variety of
potential causes that must be considered as part of a thorough investigation.
History and physical examination are crucial in guiding diagnostic testing
and tailoring management strategies.
Symptoms of constipation are often under reported. The diagnosis is made
clinically.
Medications are often required and should be titrated to achieve one, soft,
easy to pass bowel action per day
5. Introduction
Gastrointestinal motility is a complex process, which is often altered
during critical illness, that can lead to constipation.
There is no consensus definition for constipation and it is therefore
difficult to accurately assess incidence across studies.
More recently, the term “Paralysis of the lower gastrointestinal tract” has
been suggested.
Constipation can cause abdominal distension and discomfort, and reduce
tolerance to enteral feeding.
6. It can impair respiratory function and has been associated
with worse patient outcomes including prolonged ICU length
of stay and prolonged mechanical ventilation.
Management must focus on treating the underlying cause
and re-establishing regular bowel movements.
7. Do we focus on bowel pattern of patients?
Constipation is a frequent problem in ICU patients, but is
often overlooked.
Focus is on management of disease and not on such
symptoms
Staff often react more quickly to diarrhea, which is usually
obvious, than to Constipation, which is often less apparent.
9. What is definition of
constipation?
In the general population,
Subjective: Criteria as explained by general
population/patient (straining, hard stool, sensation of
incomplete bowel movement or anorectal blockage)
Objective : The Rome criteria are frequently used,
[assessing ( <3 stool frequency stool movements per
week], need for manual maneuvers to defecate)
However, in critically ill patients, subjective symptoms are often difficult to assess and a
diagnosis of constipation essentially relies on absence of defecation, although the
chosen time period varies among studies.
10. Because of the subjective nature of constipation:
Some debate the use of the term “constipation” in critically ill patients
A recent Working Group on Abdominal Problems from the European
Society of Intensive Care Medicine recommended that the term
“Paralysis of the lower gastrointestinal (GI) tract”
Other synonym: Gut Hypomotility
12. Definition of Constipation
The American Gastroenterological Association
defines constipation as
Infrequent bowel movements typically fewer than 3
per week, patients have a broader set of symptoms,
including hard stools, a feeling of incomplete
evacuation, abdominal discomfort, bloating, and
distention, as well as other symptoms e.g.,
excessive straining, a sense of anorectal blockage
during defecation and the need for manual maneuvers
during defecation.
13. “Paralysis of Lower Gastrointestinal Tract”
They defined this as “The Inability of the bowel to pass stool
due to impaired peristalsis”
Clinical signs would include
Absence of stool for >3 consecutive days without mechanical
obstruction regardless of bowel sounds.
Bowel sounds (which have been widely used as an indicator of bowel
activity), are unreliable and should not form part of the diagnostic
criteria. Marik PE,Crit Care Med 2014;42:962-9
15. Incidence
Multiple research studies reflecting that incidence of constipation in ICU ranges
from 25% to 90%.
Fukuda S et al in 2016 conducted retrospective study showed that 66 % patients
had defecation at ≤5 days and 34 % patients had defecation ≥6 days.21
Many other studies also reported higher incidence of constipation in ICU which
requires treatment.
But while treating constipation by laxatives, enemas, etc, we may end up with
increased frequency of bowel pattern i.e. Diarrhea.
We require to be very
careful and vigilant in
treating constipation
16. Various Research Studies
report….
Need for treatment with
laxatives or enemas
Failure of bowel to open
Late defecation with
first defecation at
mean of >6 days
Lower GI tract paralysis
17. Constipation occurred in 69.9% of the patients.
There was no difference between constipated and not
constipated in terms of sex, age, Acute Physiology and
Chronic Health Evaluation II, type of admission (surgical,
clinical, or trauma), opiate use, antibiotic therapy, and
mechanical ventilation. Early (<24 hours) enteral
nutrition was associated with less constipation, a finding
that persisted at multivariable analysis (P < .01). Antonio
Paulo Nassar Jr et al
18. Inadequate bowel pattern in
62% subjects: Constipation
(90.3%) & Diarrhea (9.6%)
Adequate bowel pattern in
38% subjects. Among which
42% had adequate bowel
with laxatives
Significant association of
late Enteral Nutrition (RR
1.99, p=0.001) with
constipation and increased
the risk of intubation for
>6days
21. Classification as per Cause
Constipation is a common symptom that may be due to some
cause or disorder
Primary (idiopathic or functional) it is further
classified as per presence or absence of Abdominal pain,
Colonic transit time , Pelvic floor dysfunction.
Secondary : Constipation can be attributed to multiple
causes such as lifestyle, systemic diseases etc.
23. Primary Constipation
The Rome criteria has been established to distinguish
between functional constipation and IBS-C, and the two
definitions are mutually exclusive.
The main distinction is that patients with IBS-C complain
predominantly of abdominal pain or discomfort.
26. Bristol Stool
Chart
The Bristol stool scale is a
diagnostic clinical
Assessment tool designed to
classify the form of human
faeces into seven categories.
It was developed at the Bristol
Royal Infirmary as a clinical
assessment tool in 1997
It is widely used as a research
tool to evaluate the
effectiveness of treatments for
various diseases
30. Clinical impact of constipation
Constipation can cause
Abdominal distension and discomfort
Poor tolerance of enteral feeding
Confusion
Intestinal obstruction with vomiting and risk of pulmonary aspiration
Raised intra-abdominal pressure which can impact on respiratory
function.
Abdominal distension associated with constipation may be associated
with bacterial overgrowth increased bacterial translocation
31. Clinical impact of constipation
Gacouin et al. reported reduced bacterial ICU-acquired infections in
patients who passed stools early (< 6 days) rather than late (> 6 days).
Constipation in critically ill patients has been associated with worse
outcomes including
Prolonged ICU length of stay
Prolonged mechanical ventilation.
More severe illness, as indicated by higher APACHE II scores.
Patanwala et al.
35. Factors affecting constipation
Spinal cord injury.
Recent abdominal surgery is a common cause, (although the delay
before first defecation in these patients can vary considerably)
Anesthesia and analgesia effect
Immobility
Unconscious / Sedated Patients
Sepsis: enhance the inhibitory effects of opioids on colonic motility
via Toll-like receptor, a key signaling molecule in sepsis
pathogenesis.
Electrolyte disturbances, including
Hypokalemia
Hypercalcemia
Hypomagnesemia
36. Inadequate fluid administration or inappropriate use of diuretics
leading to dehydration
Excess fluid administration can lead to splanchnic edema, impairing
gut motility.
Drugs that reduces intestinal secretions and gut hypomotility
•Morphine and other opioids
•Inotropes (dopamine)
•Phenothiazines
•Diltiazem
•Verapamil,
•Anticholinergic drugs
• Aluminum containing antacids
• Iron supplements,
• Calcium Supplements
• Antipsychotics
• Vasopressors
37. Hypotension, independently associated with late (> 6 days) passage of first
stools
PaO2 /FiO2 ratio of 1.40 [95% confidence interval 1.06-1.60],
p=0.003)
Obesity: Constipation rates in obese and overweight subjects range
from 17.2 to 29.4%
Elderly (Geriatric population)
Female Gender (women 50% vs Men 29% )
Late Enteral Nutrition : Many studies have reported the delay in EN causes
constipation
38. Interaction with Enteral feeding
Delayed administration of EN may contribute to constipation
Early EN is recommended in critically ill patients.
Early EN was associated with a significantly shorter time to first
defecation compared to early parenteral nutrition (PN) in patients
undergoing major rectal surgery. Boelens et al.
Continuous EN is usually recommended to improve the delivery of
nutrients.
However, meals and bolus delivery of nutrients cause gastric and colonic
distention, leading to increased antro-pyloric pressure waves and motility.
Kadamani et al. reported that continuous EN was associated with more
constipation than bolus EN.
40. Normal Colonic Physiology
The colon mainly absorbs water and electrolytes.
On average, up to 2 L of fluid are resorbed daily, with generally only 100
mL of fecal fluid loss.
In addition, hundreds of species of bacteria live in the colon; bacterial
fermentation creates up to 10 L of mixed gas per day, the majority of
which is absorbed versus expelled.
Smooth muscle contractions propel ingested nutrients through the
colonic conduit and determine the time available for digestion and
absorption.
41. Neural control of the colon
It arises through the autonomic and enteric nervous systems.
Sympathetic motor activity is mediated by α2-adrenergic receptors and is
generally excitatory to the sphincters and inhibitory to the non-sphincter
musculature.
Parasympathetic motor activity is usually excitatory to the smooth
muscle and originates from the vagus nerve and sacral nerve plexus.
The enteric nervous system is a complex and highly organized
arrangement of neurons that involves two major ganglionic plexuses.
The submucosal (Meissner’s) plexus primarily regulates mucosal functions of
the colon,
The myenteric (Auerbach’s) plexus, located between the inner circular and
outer longitudinal muscle layers, is responsible for motor activity.
42. Colonic motor activity
Colonic motor activity is more irregular than that of the upper GI tract.
Non-propagated contractions: segmental activity (occur in isolation or
short bursts)
Propagated contractions: high- or low-amplitude.
High-amplitude propagated contractions generally occur upon
awakening and after meals and are responsible for the mass
movement of contents through the colon
Low-amplitude contractions can be associated with abdominal
distension or flatus.
Increased colonic motor activity is seen postprandially and
is referred to by the somewhat misleading term, “gastrocolic
reflex”
44. Ultimate Goal:
Treatment of constipation among hospitalized
patients
Evaluation of constipation begins
Detailed history
Physical examination
Adequate visual and digital anal examination.
Looking for presence of alarm symptoms
46. Management of Constipation
Goals
Assess early
Reestablish and maintain regular bowel
movements
Manage early
Prevent further complications or worsening
47. Management of constipation in hospital
Routine assessment of bowel movements
Treating the underlying cause
Adjuvant Therapy (Non-Pharmacological Management)
Pharmacological management
Prophylaxis for Constipation
Constipation prevention Bundle approach
48. Routine Bowel Assessment
On Admission:
Be aware
Take relevant history
Normal BM routine—daily, weekly, etc.
Time and type of last stool (if possible)
Ability of patient to sense the urge to defecate
Regular laxative medication
Known bowel disorder (IBS, inflammatory bowel disease)
Identify potential risk factors (opiate use, prolonged immobilization, …)
Consider starting prophylactic laxative agents, especially if risk factors
present or taking laxatives prior to admission
49.
50. No Bowel Movement within Past 24 Hours:
Correct electrolyte abnormalities and confirm adequate hydration
Evaluate need for ongoing opiate analgesia and other “constipation
causing” drugs
Abdominal and rectal exam for presence and nature of stools - disimpact
if necessary
If already receiving prophylactic laxative, increase dose.
If not, start laxative (lactulose, PEG, docusate, senna…)
Re-evaluate daily and increase laxative dose or add a second agent if no
response
If still no response after 24 hours, repeat rectal exam and consider enema
Consider abdominal x-ray to rule out ileus, impaction, pseudo-obstruction
51. Treating the Underlying Cause
Full physical examination :
Rectal examination and imaging when necessary
to exclude the presence of any mechanical obstruction
that requires surgical management.
Correct Electrolyte imbalances
Optimize Fluid administration
Regularly review the need for analgesic agents
52. Adjunct Treatment (Non-Pharmacological)
Educate and encourage patient participation (if conscious)
Mobilize patient if possible
Mobilize the patients (with/without assistance) for a short walk in ward or
corridor
ROM (Active & passive) exercises for bed ridden patients
Include dietary Fibre Supplementation
Soluble dietary fiber (eg, psyllium or ispaghula) supplements
Fiber supplementation over 7-10 days
Bowel Training /technique of correct defecation)
Biofeedback Therapy for constipation
54. Benefit of Indian toilets over
western toilets
Better position to defecate
55. Biofeedback mechanism
(Neuromuscular training )
The goal is to restore a normal pattern of defecation.
Based on “operant conditioning” techniques.
Governing principal is any such as muscle contraction-when reinforced its
likelihood of being repeated and perfected increases several fold.
In dyssynergic defecation: the goal of neuromuscular training is two-fold
Early studies indicate that biofeedback therapy
improves gut and brain interaction.
56.
57. Treated in acquired behavioral
disorder where the act of stooling is
uncoordinated or dyssynergic ,
inadequate push effort or
incomplete anal relaxation with or
without altered rectal sensation
Treated by Neuromuscular training or
biofeedback therapy
59. Pharmacological Treatment
Laxatives and Enemas
There are essentially two types of treatment for constipation after efforts
have been made to remove the underlying cause:
Oral laxatives
Bulking agents
Osmotic laxatives
Stimulant laxatives
Stool softeners
Suppositories
Enemas
60. Bulk laxatives
Safe & natural way to treat constipation
Absorbs water to increase bulk
Distends bowel to initiate reflex bowel activity
Increases volume of intestinal contents forming large,
soft stool
E.g. Methylcellulose, Ispaghul (Plantago seeds),
bran, linseed
61. Stool Softeners
Docusate Sodium (dioctyl sodium
sulphosuccinate): Softens surface tension of
intestinal contents. Allows more water to be retained in
stool which becomes soft
Liquid paraffin (emolients) is a mineral oil
that is not digested. It lubricates and softens
faeces.
62. Osmotic/Saline laxatives
These are solutes not absorbed in intestine, osmotically retain water and
increase the bulk of intestinal contents. They increase peristalsis & expel
a fluid stool
E.g.
Lactulose : synthetic disaccharide that is not absorbed, holds water & acts as
osmotic purgatives
PEG: Polyethlene glycol has high water binding capacity, iso-osmotic in nature
Magnesium hydroxide (Milk of magnesia)
Magnesium sulphate
Sodium potassium tartrate
Sodium sulphate
63. Stimulant Laxatives
Increase intestinal motility & increase secretions of water &
electrolytes by mucosa
Evacuation takes 6-8 hours
E.g.
Phenolphthalein
Bisacodyl : orally 5mg/rectal suppository 10 mg (defecation in 15-30
min)
Castor oil: powerful & oldest purgatives, increases intestinal motility,
less preferred
64. Prophylaxis for constipation
Lactulose (osmotic laxative) - starting dose of 10 ml twice a day
increasing to a maximum of 20 ml three times daily recommended
prophylactically
Lactulose use results in uncomfortable bloating in some patients.
Senna (10 ml/day) is a commonly used alternative
Polyethylene glycol (PEG) (osmotic laxative) is also widely used and
can be administered intermittently or continuously.
Enemas are generally reserved for patients in whom
orally administered laxatives do not have an effect.
66. Constipation prevention
bundle
The goal is to prevent significant constipation by
intervening early, improving the prescription of laxatives,
and titrating them when the constipation has resolved.
This involved
Educational sessions
Non-pharmacological alternatives to laxatives
Optimisation of hydration, exercise, and high fibre foods
Laxative prescription guidance
Twice weekly laxative ward rounds
Maintaining Stool Chart (using Bristol stool Chart)
67. Bundle of prevention of constipation
(Non-pharmacological management)
Start early enteral nutrition
Start early mobilization
Select laxative and/or prokinetic/s to manage
constipation.
Optimize and/or decrease doses of opioids and
sedatives (Sedation vacation)
Pharmacological reconciliation
Nurses Role (5
R’s)
•Re-assess
•Re-evaluate
•Re-consiliation
•Record
•Report
68. Constipation care Bundle/Pharmacological Protocol
First 48 hours
Polyethylene glycol 3350 (about 17 grams) 1 every 8 hours enterally.
Patients with vomiting and / or gastric residue greater than 500 mL (in a
timely measurement every 6 hours) will also be given domperidone 10 mg
every 8 hours intravenously.
Patients who have excessive abdominal distension to be administered in
addition, levosulpiride 25 mg every 8 hours intravenously.
48 hour Evaluation:
Patients who do not have bowel movements
Administer lactulose or sodium phosphate enema.
Administration of neostigmine intravenously or of naloxone enterally
Doses of polyethylene glycol 3350 to be adjusted as per bowel
movements
Prokinetics to be adjusted, for a maximum of 5 consecutive days
71. Role of Neostigmine
Many studies have shown the efficacy of neostigmine,
an acetylcholinesterase inhibitor at a single dose of 2
mg of intravenous or intravenous saline in functional
colonic pseudo-obstruction, may be considered to
increase peristalsis and promote gut motility.
Ponec et al. in which 21 patients with acute colonic pseudo-obstruction
with no response to > 24 hours of conservative treatment, were
randomized to receive a single dose of 2 mg of intravenous
neostigmine or intravenous saline. Ten of the 11 patients who
received neostigmine had rapid evacuation of flatus or stool, with a
median time to response of just 4 minutes, as compared with none of
the 10 patients who received placebo (p< 0.001
72. Summary
Constipation is preventable and treatable
Early assessment & Nurse’s observation can prevent
complications caused by constipation
Early Enteral Nutrition and prophylaxis can reduce the hospital
stay and early recovery
Implement Constipation prevention bundle approach/protocol
73.
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Editor's Notes
Reintam Blaser A, Malbrain ML, Starkopf J, et al. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Intensive Care Med 2012;38:384-94.
Marik PE. Enteral nutrition in the critically ill: myths and misconceptions. Crit Care Med 2014;42:962-9.
Colonic transit time: averages about 36 hours
Orocaecal transit time: average of 6 hours