Table 4 outlines a systematic approach to the treatment of chronic constipation. This scheme assumes that any specific etiologic factors have been identified and dealt with appropriately.
|TABLE 4 Approach to Treatment of Chronic Constipation|
|1.||Ensure adequate fluid intake (approximately 2.5 litres per day, i.e. roughly eight 10oz. glasses)|
|3.||High fiber diet and/or bran and/or psyllium preparation.|
|4.||Try to establish regular defecation time, eg. 20-40 minutes after breakfast or supper. Whenever possible, attempt at defecation should be made in sitting position on commode or toilet; bedpan should be avoided.|
|5.||If no spontaneous bowel movement, glycerin suppository on second day and at two-day intervals thereafter, approximately 30 minutes before planned bowel movement.|
|6.||Attempt to wean from suppositories once regular pattern of bowel movements is established.|
The apparently simple issue of ensuring adequate fluid intake can be difficult in patients who are occasionally or regularly incontinent of urine. Such patients may be making a conscious effort to restrict fluid intake in order to minimize problems of urinary incontinence and may therefore be resistent to suggestions that they drink more.
For bedridden and semi-ambulatory patients there may be limited potential for increased physical activity. Nevertheless, an effort should be made to see that they are as active as possible within the limits imposed by their medical condition.
Virtually any elderly person should be able to tolerate at least one of the alternatives of bran, high fiber diet or a psyllium preparation. Whichever alternative is chosen, the objective should be soft, formed stools. Foods other than bran which are rich in fiber include raw fruits, especially figs, apples, oranges and prunes, with skins and seeds, vegetables, especially raw and green, leafy vegetables and whole grain cereals and breads. Unprocessed bran is available in supermarkets as Quaker Natural Wheat Bran.
The required dose of a psyllium preparation such as Metamucil can vary greatly from patient to patient. The appropriate dose is that required to produce soft stools.
Most patients outside institutions will find a psyllium preparation more acceptable than bran or a high fiber diet. Many elderly are not anxious to alter long-established dietary habits and methods of food preparation. Psyllium preparations may also be more attractive because they are available to elderly patients at no cost through the provincial drug benefit plan, whereas a high fiber diet may entail significant additional expenditure. Bran, on the other hand, is cheap — a month’s supply costs under a dollar.
For institutionalized patients, a high fiber diet or the addition of unprocessed bran to foods deserves serious consideration. Many mentally impaired patients cannot be induced to take psyllium preparations but might not object to a high fiber or bran supplemented diet.
For most ambulatory patients, ensuring adequate fluid intake, increasing activity and improving stool bulk will provide relief of constipation. However, in debilitated patients and chronic users of oral laxatives a program of bowel training will usually be necessary. In laxative-dependent patients that program must include a plan for the elimination of oral laxatives.
Attempting defecation after meals takes advantage of the gastrocolic reflex. Whether breakfast, lunch or supper is chosen will depend on the patient’s’ previous pattern of defecation when that is known. No patient should remain on a toilet, commode or bedpan for longer than 20 or at the very most 30 minutes. Privacy favors success. If at all possible, an attempt at defecation should be made in a sitting position on a toilet or commode. The upright position takes advantage of gravity and facilitates efforts to bear down.
Some patients may need aids such as a handrail, back rest or raised toilet seat. It is often helpful for the feet to be elevated on a stool, approximating the classic squat position for defecation. The patient should be instructed to lean forward slightly if he is able and to bear down gently by contracting the abdominal muscles and lowering the diaphragm. The patient should remove himself or be assisted off the toilet or commode if no bowel movement occurs within a specified time. Unless the patient later experiences a distinct urge to defecate, no further attempt should be made until the same time the following day.
Suppositories can be useful in helping to establish a bowel routine. Timing of insertion is important. For example, when a post-breakfast bowel movement is desired, a glycerin suppository should be inserted immediately after the meal and a bowel movement attempted in about 30 minutes. This procedure takes full advantage of the combined effect of the suppository and the gastrocolic reflex. Since there is considerable variation from patient to patient in response time to suppositories, insertion time will have to be adjusted accordingly. Glycerin, and for that matter all suppositories, should be inserted against the rectal wall and not into the fecal mass. The occasional patient will fail to respond to suppositories and will require enemas initially in establishing a bowel routine. Most patients who require suppositories or enemas will be able to discontinue them once a regular pattern of bowel movements every one, two or even three days is established.
Patients with decreased rectal awareness — for example severely demented patients — may accumulate stool in the rectum even if stools are soft and transit time normal. Although they may respond to vigorous efforts at bowel training, some may require suppositories or enemas on a longterm basis. This may also be true of patients with neurologic disorders such as advanced multiple sclerosis and spinocerebellar degeneration.
Oral laxatives other than bulk-forming laxatives are not mentioned in this proposed approach to chronic constipation. This is not an oversight. I believe that stimulant, saline and even emollient laxatives have little role to play in the treatment of chronic constipation.