CATEGORY: - Jail Medicine



Sample Guideline: Constipation

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policy on constipation. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Constipation is a common complaint in correctional medical clinics. While constipation may be only a nuisance in some patients; constipation can also be a symptom of a more serious problem in others. This guideline serves to guide appropriate evaluation of complaints of constipation.

Definitions.

Constipation. Constipation is a subjective complaint of straining, decreased frequency, and/or decreased volume of bowel movements. A normal frequency of bowel movements ranges from three times a day to three times a week. (Essential Evidence Plus)

Complicated Constipation. Patients with complicated constipation have one or more of the following complicating factors.

1. Significant abdominal cramping or pain

2. Abnormal vital signs, especially fever or tachycardia.

3. Severe rectal pain or bleeding

4. Age greater than 65

5. Chronic debilitating disease such as AIDS, cancer or patients on immunomodulating drugs.

6. Chronic intestinal disorders such as Crohn’s Disease, ulcerative colitis or cystic fibrosis.

7. Chronic and current use of high-dose narcotics.

Uncomplicated Constipation. Patients with uncomplicated constipation have no complicating factors. Common causes of uncomplicated constipation include:

1. Perceived constipation. Some patients are not constipated at all, but simply misunderstand normal bowel habits. For example, it is common for patients to erroneously think that they need to have a bowel movement every day.

2. Dehydration. If patients allow themselves to become dehydrated, the colon will reabsorb all available water resulting in small, harder-to-pass stools.

3. Poor diet. Eating too little fiber causes stools to be small and harder to pass.

4. Change in residence or diet. It is common to have temporary constipation upon moving or switching to a new diet, such as when inmates become newly incarcerated.

5. Poor bowel habits. Patients who consciously resist the impulse to have a bowel movement may not be able to easily move their bowels later.

Evaluation of Patients Complaining of Constipation

Patients complaining of constipation should have an evaluation including:

1. History of current constipation issues.

2. Past history of constipation issues, including medical evaluations, procedures and previous prescriptions. Relevant medical records should be requested.

3. Vital signs and weight

4. Abdominal exam

5. A rectal exam by a practitioner is usually necessary in patients with complicated constipation.

Uncomplicated Constipation

Patients complaining of constipation who have no complicating factors may be initially cared for by the nursing staff as outlined in this guideline.

1. The patient should be educated about normal bowel function and the importance of hydration and fiber. The Constipation Education Handout may be used for this education.

2. Patients should be directed to therapies for uncomplicated constipation available on the commissary, which should include OTC fiber and stool softeners.

3. Persistent complaints of unresolved constipation, even without complicating factors, should be referred to the medical clinic.

Complicated Constipation

Patients complaining of constipation with any complicating factors should be referred to a medical practitioner. The medical practitioner should obtain an adequate history of the patient’s current complaint and previous medical history relating to constipation and complicating factors. Several medications can cause or exacerbate constipation, including.

The medical practitioner should perform an appropriate physical examination including vital signs, weight and an abdominal examination. A rectal exam should be considered in every case of complicated constipation to ascertain the presence or absence of a rectal stool mass and to check for anal pathology such as fissures or hemorrhoids that can cause constipation. The absence of any stool in the rectum may also be an important finding incongruent with the history of severe constipation.

One view flat plat abdominal x-ray may be used to assess persistent complaints of constipation that are incongruent with physical examination.

Labs may be considered in complicated cases or when symptoms persist despite treatment.

Persistent severe constipation may require consultation with a specialist, colonoscopy or advanced imaging.

Treatment of constipation

Various agents are available for the treatment of constipation. Choice of the best therapeutic agent depends on several factors including complicating factors, the age of the patient and severity of symptoms. Therapeutic options include the following.

1. Abnormal factors found on exam affecting constipation should be treated. Examples include disimpaction of large fecal masses and treatment of anal lesions such as hemorrhoids or fissures.

2. Consider discontinuing or reducing the dose of medications that can cause constipation.

3. Patient education on proper bowel habits and the importance of fiber, hydration and exercise.

4. Fiber. This is the mainstay of constipation therapy and the most important therapy that can be offered. Many patients do not get enough fiber from the jail diet. Supplements include capsules (like Fibercon) and powder that should be mixed with water (like Metamucil). These are OTC preparations which ideally should be offered on commissary.

5. Softening agents include mineral oil and Docusate (colase). These retard water absorption from the stool to create bigger, softer feces. The same effect can be accomplished by having the patient drink more water.

6. Osmotic laxatives such as polyethylene glycol, lactulose or magnesium hydroxide are preferred over stimulant laxatives. Ideally, they should be used on a prn basis.

7. Stimulant laxatives such as bisocodyl and senna stimulate the colon to contract more forcefully. These can be habituating and ideally should be reserved for occasional use of no more than three days except in extraordinary circumstances.

8. Newer agents such as linaclotide and lubiprostone may be considered for chronic severe constipation, usually after consultation with a specialist.

9. High colonic, large volume enemas should not routinely be administered in the jail. These may be used only if other, less invasive procedures have failed. The jail Medical Director must approve any use of enemas in advance.

References:

Uptodate. Management of Chronic Constipation in Adults. March 5, 2019.

Prescriber’s Letter. Treatment of Constipation in Adults. April 2019

Essential Evidence Plus. Constipation (adult). November 2018.

Constipation Education for Patients

Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.

Some people think they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or only twice a week, depending on the person.

Constipation is a symptom, not a disease. Almost everyone experiences constipation at some point in their life, and a poor diet typically is the cause. Most constipation is temporary and not serious. Understanding its causes, prevention, and treatment will help most people find relief.

Those who are at risk for constipation include elderly, disabled, those who use or abuse narcotics, and those who are pregnant.

What causes constipation?

• not enough fiber in the diet

• lack of physical activity

• medications

• changes in life or routine such as pregnancy, aging, and change in diets or living habits

• abuse of laxatives

• ignoring the urge to have a bowel movement

• dehydration

What can you do to help maintain healthy bowel habits?

• Increase your daily intake of fiber. Be sure to eat all of your fruits and vegetables provided to you on your meal trays. You may buy fiber from the commissary to help as well.

• Drink plenty of water. Many people do not drink enough water, which can cause hard, dry, stools that are difficult to pass.

• Increase your daily activity. Exercise more, at least 1 hour or more daily. Walking is a great exercise to increase bowel activity.

• Avoid eating “junk food” such chips, snack foods and processed foods.

• If you feel the urge to use the restroom, don’t ignore it.

What should you do next?

Remember even a small bowel movement is still a bowel movement. If you have a small bowel movement it may be another few days before you have another one and that is ok. Try all the recommended things to try listed above. If you have tried all of the items listed above and are still constipated, please submit a medical request to see the medical practitioner

Source: National Institutes of Health/Health Information/Digestive Diseases/Constipation.

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