A Constipation Cocktail

In Medical Concepts by Brent Thoma4 Comments

Constipation, as defined succinctly by Urban Dictionary, is when you’ve gotta go, but your ass says “no!” It is a diagnosis that I can truly empathize with – who hasn’t been at least a bit bunged up before?

The constipated patients that present to the ED take this everyday ailment to a whole new level. No one shows up a little constipated. Those that know they’re constipated come in as a last resort after trying the homemade remedies they saw on Dr. Oz. Those that don’t are diagnosed through a combination of clinical acumen, exclusion and a FOS x-ray. Regardless, it’s no fun to deal with for the nurses, the doctor or (most importantly) the patient. Regardless, they’re sick and tired of it and they want YOU to fix it. Help them Obi-Wan Kenobi, you’re their only hope.

While I have diagnosed and treated constipation, I didn’t have a great understanding of the treatment options or have a good Cocktail of my own. I suspect this is because:

-As a resident on the ward, I don’t actually take care of constipation. On the wards the nurses are monitoring the patient’s bowels and noting what treatments have been tried and worked (or didn’t).
-In the ER, I don’t know if my remedies worked or not unless there were instant results because my follow-up of constipation cases is nonexistent.
-Constipation cocktails seem to be as numerous as the bartenders that mix them with many doctors having their own “special recipe” and different services (ie gen surg vs peds vs obstetrics vs internal medicine) having different approaches at my institution. This has given me some experience with many treatments but minimal experience with any specific one.
-Poop, like me, doesn’t make it onto EMCrit. Scatology just ain’t that cool.

To make up for my ignorance, I have developed coping/survival strategies such as ordering whatever the nurses on the ward ask for (at least that way if it doesn’t work it’s not blamed on me) and, when in the ED, picking something the patient hasn’t already tried and sending them home to deal with their situation in precious privacy. I really wish I could just order up some lactu-seno-pico-glycol and let ‘er buck, but because I can’t it’s time to learn about it: BoringEM Style.  My goal for this post is to delve into a Constipation Cocktail in sufficient depth to adopt it for my own practice (and maybe yours?).

Rather than coming up with my own untested Cocktail, I have adopted one that I was introduced to through #FOAMed on ERCast’s Constipation Manifesto podcast.  Thanks to Rob Orman for his excellent podcast and Dr. Aaron Wall for sharing his recipe.

Dr. Wall’s Constipation Cocktail (aka the Orange Poly-Fleet – sounds yummy):

-Perform manual disempaction if indicated by stool in the rectal vault (the podcast has a great overview of an approach for this procedure)
-Provide 1/2 bottle (8oz or ~250mL) of Magnesium Citrate orally in the ED
-Advise the patient to mix 3-4 17g doses of Polyethylene Glycol daily until a soft stool is produced and then mix 1 17gdose daily for 3-4 weeks
-Recommend 1-2 Fleet Enemas daily for the next 2 days
-Counsel the patient to stop/limit the use of offending agents and to maintain well hydrated with oral fluids

So how do these drugs work? What are their contraindications? Complications? What should I tell the patient to expect?   How much will they cost?

A Constipation Cocktail

Manual Disempaction
These are available free to all Canadians through sponsorship by our government (although you might have to wait in the queue for a bit).  See the ERCast podcast for an excellent overview of how to perform this procedure.  I’ve done it as many times as ZDogg.

Magnesium Citrate
It’s a generic, OTC osmotic laxative aka Citromag that is made up of magnesium and citric acid.  As the magnesium salt is poorly absorbed in the intestine, fluid is retained in the bowels.  This fluid should soften the stool by increasing its water content and also increase the intraluminal pressure to help push things along.  Notably, it should be given on an empty stomach with water.  Because it contains magnesium, hypermagnesemia (hypotension/resp depression) is a possible complication and it should be used cautiously in patients with poor renal function.  As an osmotic diuretic, other electrolyte abnormalities could develop and are more likely with frequent/excessive use.  There have also been case reports of paralytic ileus secondary to hypermagnesemia.  The patient should be told to expect increased abdominal cramping and flatulence.  If they are purchasing the product themselves a 16oz bottle (2 doses) costs <$10CAN. While I found multiple articles mentioning Magnesium Citrate’s use for treating constipation, I could not find any addressing its efficacy or safety in the ED population. Anecdotally, it is stronger than PEG which is why it is a good drug to get things started.

Polyethylene Glycol
It’s a polyether (go-go gadget organic chemistry!) compound aka PEG, GoLYTELY, Miralax and multiple other names that is available OTC and works through a similar osmotic mechanism.  It is relatively inert in the gut as it is not metabolized or absorbed and it comes as a tasteless, odorless powder that dissolves in water.  As an osmotic laxative, electrolyte imbalances can develop.  However, a version called “PEG 3350” is available that has added electrolytes to minimize this risk.  It should be taken with the recommended quantity of water to prevent the osmosing of fluid into the intestine from the body. The patient should be told to expect bloating, cramping and flatulence.  The Orange Poly-fleet-recommended 4 week supply would cost the patient approximately $20CAN.  Long-term use has been studied and found to be both safe and effective.

Fleet Enema
Pop quiz: how many kinds of “Fleet Enema” are there?  Unbeknownst to me, the name “Fleet” is attached to every bowel-aid made by the FleetLabs Corporation.  This includes at least 4 different enemas (Fleet Saline, Fleet Extra, Fleet Bisacodyl & Fleet Mineral Oil).  At my institution, a “Fleet Enema” is synonymous with a “Fleet Saline Enema” and I’ll assume that is what Dr. Wall referred to in his ERCast podcast. This enema also works through an osmotic effect as it consists of a hypertonic solution of sodium phosphate.  However, rather than just preventing the absorption of water by the colon, it draws water in.  This promotes evacuation, generally within minutes.  There are multiple case reports of complications secondary to sodium phosphate enemas including dehydration, hypotension, hyperphosphatemia, hypocalcemia, hypernatremia and hypokalemia.  This was most recently discussed in a case series in JAMA published in February of 2012 that recommended using them only in low-risk patients.  Unfortunately, I did not find any studies assessing the safety or efficacy of sodium phosphate Fleet Enemas in the ED constipation population.  As with any enema, the patient should expect fecal urgency and anal discomfort.  Fleet enemas can be purchased OTC for <$5CAN.

In conclusion, with some reservations about Fleet Enemas, I am happy to have a Constipation Cocktail to use as if it were my own.  I’d be very interested to hear about the Constipation Cocktails that others are using, as well as any further discussion on the safety of Fleet Enemas.  Is everyone still using them? Any thoughts on alternatives?

That’s it for this week! Once again I’d like to thank everyone for supporting my baby of a blog.  In particular, thanks to those that tweeted/retweeted my posts, to Mike Cadogan @sandnsurf for the welcoming messages, advice and intro to the blogging community, and to Rob Orman @emergencypdx for the podcast referenced in this post.

Happy Holidays!

Brent Thoma @boringem

Additional references:
Pharmacologic information on the discussed drugs from epocrates

Dr. Brent Thoma is a medical educator, blogging geek, and trauma/emergency physician who works at the University of Saskatchewan College of Medicine. He founded BoringEM and is the CEO of CanadiEM.