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.

2. Magnitude of the problem

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

4. Introduction

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.

8. What is definition of
constipation?

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

11. Definition

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

14. Epidemiology

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

19. Classification of
constipation

20. How we can classify
constipation?

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.

22. Classification as per cause

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.

24. Rome III Criteria: Functional Constipation
2 or more of
the following

25. Rome III Criteria: IBS-C

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

27. Types of Secondary Constipation

28. Secondary Constipation

29. Clinical Impact

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.

32. Possible complications with constipation
Pulmonary aspiration
Delayed gastric
emptying

33. Factors affecting
Constipation

34. Risk Factors : Demographic, lifestyle & medical factors

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.

39. Pathophysiology of
constipation

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”

43. Alarm Symptoms

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

45. Management of
Constipation

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

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

53. Bowel Training /technique of correct position for
defecation)

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.

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

58. Constipation treatment
regime

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.

65. Constipation Prevention
Bundle

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

69. Research studies

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

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