- Assess and treat underlying causes of constipation; including opioid induced constipation
- An abdominal flat plate can be useful to identify severity of significant fecal loading and rule out bowel obstruction
- Non-pharmacological and pharmacological interventions are often required together.
- Be aware that constipation may trigger hepatic encephalopathy
Constipation Diagnostic criteria – at least 2 symptoms for at least 3 of the last 6 months:
≤ 3 spontaneous BMs per week ; Hard or lumpy stools (Bristol type 1-2), Straining during defecation ; Sensation of incomplete evacuation ; Sensation of anorectal blockage ; Manual maneuvers to facilitate defecation.
With severe constipation, additional signs and symptoms can include nausea/vomiting, abdominal cramping, distension or overflow diarrhea.
Note: Surfactant laxatives such as Colace have been taken off most formularies due to insufficient evidence.
In difficult to treat cases, an abdominal flat plate should be carried out in order to identify fecal loading, stool distribution and determine if a full bowel cleanout is needed before starting or changing to a new bowel regimen.
If it is evident that constipation is not multifactorial, but caused by opioids only, can attempt treatment per (Fraser Health Document LINK)
- Always prescribe prophylactic laxatives alongside an opioid prescription. Avoid bulk forming laxatives.
- While Domperidone and Maxeran can help with constipation in the occasional patient, these prokinetic agents are generally ineffective in the colon
- Re-evaluate pain scores, response to opioid, and need for current opioid dose.
- Decrease the opioid dose if possible.
- If opioid doses are increasing, the dose of laxatives often needs to be increased as well. Evaluate tolerance frequently, holding the laxatives for 1 – 2 days if laxative associated diarrhea occurs
Patients continue to produce stool until the last hours of life. Continue stimulant suppositories q3 days if no bowel movement to prevent abdominal discomfort.
This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon
Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages.
- Hepatic Encephalopathy:http://cirrhosiscare.ca/treatment-provider/hepatic-encephalopathy-hcp/
- Opioid induced constipation: Fraser Health Opioid Induced Constipation
- Alberta Health Services Constipation pathway: https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-dh-pathway-constipation.pdf
- Alberta Health Services Patient Handout for Managing constipation: https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-managing-constipation.pdf
- Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
- Pannemans J, Vanuytsel T, Tack J. New developments in the treatment of opioid-induced gastrointestinal symptoms. United European Gastroenterol J. 2018 Oct;6(8):1126-1135. doi: 10.1177/2050640618796748. Epub 2018 Aug 27. PMID: 30288274; PMCID: PMC6169055.
- Pantham G, Post A, Venkat D, Einstadter D, Mullen KD. A New Look at Precipitants of Overt Hepatic Encephalopathy in Cirrhosis. Dig Dis Sci. 2017 Aug;62(8):2166-2173. doi: 10.1007/s10620-017-4630-y. Epub 2017 May 30. PMID: 28560484.
- Pergolizzi JV Jr, Christo PJ, LeQuang JA, Magnusson P. The Use of Peripheral μ-Opioid Receptor Antagonists (PAMORA) in the Management of Opioid-Induced Constipation: An Update on Their Efficacy and Safety. Drug Des Devel Ther. 2020 Mar 11;14:1009-1025. doi: 10.2147/DDDT.S221278. PMID: 32210534; PMCID: PMC7075239.
- Starreveld JS, Pols MA, Van Wijk HJ, Bogaard JW, Poen H, Smout AJ. The plain abdominal radiograph in the assessment of constipation. Z Gastroenterol. 1990 Jul;28(7):335-8. PMID: 2238762.