Relief from behind: enemas, the back door enforcement to help treating chronic constipation in adults.

INTRODUCTION: Chronic constipation is a frequent symptom encountered in the daily clinical practice. The treatment of this condition mainly relies on the use of laxatives. However, patients' satisfaction with this approach is limited, and alternative measures are often added to the treatment. Among these, particularly frequent worldwide is the use of enemas, even though literature data on its scientific validity are scarce. AREAS COVERED: In this article, by an extensive online search of Medline (through PubMed), Scopus, Cochrane CENTRAL, EMBASE, and the Science Citation Index, the available literature data on the use of enemas in adult patients with chronic constipation, also in the perspective of available guidelines on treatment of this pathological condition, were analyzed. EXPERT OPINION: Although the use of enemas remains a frequently employed method and it is considered as useful by many physicians as an adjunctive support for the treatment of chronic constipation in adults, this practice is not substantiated by rigorous scientific data, and some studies are available only for specific instances (fecal impaction, transanal irrigation). Thus, waiting for more robust scientific data, enemas treatment should be carried out on an individual patient's basis, according to the experience of the caring physicians.

Use of gastrografin in the management of faecal impaction in patients with severe chronic constipation: a randomized clinical trial.

BACKGROUND/AIM: Faecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction. Gastrografin is a water-soluble radiologic contrast agent that may be orally or rectally administered, with proved therapeutic benefits in adhesive small bowel obstruction. Enemas have long been advocated as the best treatment for FI. The purpose of this study was to demonstrate that enteral administration of gastrografin might be more effective than enema in FI treatment inducing intestinal obstruction. METHODS: A double-blinded, controlled and randomized trial was conducted. Participants received 100 mL of gastrografin (gastrografin group) through nasointestinal tube or enemas (enema group) once daily for six consecutive days. Successful faecal disimpaction, FI time to resolution, Bristol Stool Scale, constipation severity, symptom assessment and adverse events were evaluated. RESULTS: A total of 124 patients were eligible, but only 83 were enrolled to this trial (mean age: 44 ± 15.8 years). Forty-two patients received enemas, and 41 patients received gastrografin, with six dropouts in each group. Successful disimpaction was achieved with enemas (69.44%) and gastrografin (88.57%; P = 0.034), mean duration of impaction was strikingly different between the two groups (67.13 versus 31.67, respectively; P < 0.01). Constipation severity and symptom assessment were significantly reduced in the gastrografin group. CONCLUSION: Gastrografin given through nasointestinal tube was more effective than enema in the treatment of FI inducing colon obstruction. Gastrografin might be taken into consideration as an effective and safe therapeutic option for FI.

Stercoral colitis complicated with ischemic colitis: a double-edge sword.

BACKGROUND: Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis. CASE PRESENTATION: An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia. CONCLUSION: Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Utilización del polietilenglicol como tratamiento en el estreñimiento funcional y la impactación fecal / Use of polyethylene glycol in functional constipation and fecal impaction

Objetivo: evaluar analítica y descriptivamente la evidencia publicada hasta la actualidad sobre el uso del polietilenglicol, solo o con electrolitos, en el tratamiento de pacientes con estreñimiento funcional. Metodología: búsqueda en las bases de datos MEDLINE, EMBASE y Cochrane hasta mayo de 2016 de todas las publicaciones que se ajustaran a los siguientes términos: constipation and/or fecal impaction and (PEG or polyethilene or macrogol or movicol or idralax or miralax or transipeg or forlax or golytely or isocolan or mulytely) not colonoscopy. Lectura crítica de los artículos seleccionados (únicamente en inglés o español) clasificando la descripción de los mismos en función de grupos de edad (adulto/ edad pediátrica) y, dentro de ellos, en función de las características de los estudios (evaluación de eficacia frente a placebo, búsqueda de dosis, seguridad, comparación con otros laxantes, estudios observacionales y artículos de revisión monográficos para poletilenglicol o metaanálisis). Resultados: se han seleccionado para análisis descriptivo 58 publicaciones; de ellas, 41 son ensayos clínicos, ocho son estudios observacionales y nueve son revisiones sistemáticas o metaanálisis. Doce ensayos clínicos evalúan la eficacia frente a placebo, ocho frente a lactulosa, seis estudio de dosis, cinco comparan entre sí el polietilenglicol con y sin electrolitos, dos comparan la eficacia con respecto a leche de magnesia y el resto de ensayos evalúan el polietilenglicol comparando con enemas (dos), ispágula (uno), tegaserod (uno), prucaloprida (uno), aceite de parafina (uno), combinaciones de fibras (uno) y Descurainia sophia (uno). Conclusiones: los preparados con polietilenglicol, únicos o asociados a electrolitos, son más eficaces que el placebo en el tratamiento del estreñimiento funcional tanto en adultos como en edad pediátrica con gran seguridad y tolerancia. Constituyen el laxante osmótico más eficaz (superior a la lactulosa) y de primera línea para el tratamiento de esta afección a corto y largo plazo. En la impactación fecal son tan eficaces como los enemas, evitan la necesidad de ingreso hospitalario y son muy bien tolerados por los pacientes (fundamentalmente, en su presentación sin electrolitos) (AU)

Objective: The objective of this study was to evaluate in an analytical and descriptive manner the evidence published so far on the use of polyethylene glycol (PEG), with or without electrolytes, in the management of functional constipation and the treatment of fecal impaction. Methodology: Search on MEDLINE, EMBASE and Cochrane databases until May 2016 of all publications adjusted to the following terms: constipation AND/OR fecal impaction AND (PEG OR polyethylene glycol OR macrogol OR movicol OR idralax OR miralax OR transipeg OR forlax OR golytely OR isocolan OR mulytely) NOT colonoscopy. Critical reading of selected articles (English or Spanish), sorting their description according to group age (adult/pediatric age) and within those, in accordance with study features (efficacy evaluation versus placebo, doses query, safety, comparison with other laxatives, observational studies and monographic review articles of polyethylene glycol or meta-analysis). Results: Fifty-eight publications have been chosen for descriptive analysis; of them, 41 are clinical trials, eight are observational studies and nine are systematic reviews or meta-analysis. Twelve clinical trials evaluate PEG efficacy versus placebo, eight versus lactulose, six are dose studies, five compare polyethylene glycol with and without electrolytes, two compare its efficacy with respect to milk of magnesia, and the rest of the trials evaluate polyethylene glycol with enemas (two), psyllium (one), tegaserod (one), prucalopride (one), paraffin oil (one), fiber combinations (one) and Descurainia sophia (one). Conclusions: Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability. These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term. They are as efficacious as enemas in fecal impaction, avoid the need for hospital admission and are well tolerated by patients (mainly when administered without electrolytes) (AU)

Use of polyethylene glycol in functional constipation and fecal impaction.

OBJECTIVE: The objective of this study was to evaluate in an analytical and descriptive manner the evidence published so far on the use of polyethylene glycol (PEG), with or without electrolytes, in the management of functional constipation and the treatment of fecal impaction. METHODOLOGY: Search on MEDLINE, EMBASE and Cochrane databases until May 2016 of all publications adjusted to the following terms: constipation AND/OR fecal impaction AND (PEG OR polyethylene glycol OR macrogol OR movicol OR idralax OR miralax OR transipeg OR forlax OR golytely OR isocolan OR mulytely) NOT colonoscopy. Critical reading of selected articles (English or Spanish), sorting their description according to group age (adult/pediatric age) and within those, in accordance with study features (efficacy evaluation versus placebo, doses query, safety, comparison with other laxatives, observational studies and monographic review articles of polyethylene glycol or meta-analysis). RESULTS: Fifty-eight publications have been chosen for descriptive analysis; of them, 41 are clinical trials, eight are observational studies and nine are systematic reviews or meta-analysis. Twelve clinical trials evaluate PEG efficacy versus placebo, eight versus lactulose, six are dose studies, five compare polyethylene glycol with and without electrolytes, two compare its efficacy with respect to milk of magnesia, and the rest of the trials evaluate polyethylene glycol with enemas (two), psyllium (one), tegaserod (one), prucalopride (one), paraffin oil (one), fiber combinations (one) and Descurainia sophia (one). CONCLUSIONS: Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability. These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term. They are as efficacious as enemas in fecal impaction, avoid the need for hospital admission and are well tolerated by patients (mainly when administered without electrolytes).

Soap Suds Enemas Are Efficacious and Safe for Treating Fecal Impaction in Children With Abdominal Pain.

OBJECTIVES: Constipation is a common cause of pediatric abdominal pain and emergency department (ED) presentation. Despite the high prevalence, there is a dearth of clinical information and wide practice variation in childhood constipation management in the ED. The objective of the study was to assess the efficacy and safety of soap suds enema (SSE) in the therapy for fecal impaction in children with abdominal pain within the pediatric ED setting. The primary outcome was stool output following SSE. Secondary outcomes were adverse events, admissions, and return visits within 72 hours. METHODS: The present study is a retrospective cross-sectional study performed in the ED at a quaternary care children's hospital of patients seen during a 12-month period who received an SSE for fecal impaction. RESULTS: Five hundred twelve patients (53% girls, median age 7.8 years, range: 8 months-23 years) received SSE therapy during a 1-year period. Successful therapy (bowel movement) following SSE occurred in 419 (82%). Adverse events included abdominal pain in 24 (5%) and nausea/vomiting in 18 (4%). No SSE-related serious adverse events were identified. Following SSE, 405 (79%) were subsequently discharged, of which 15 (3.7%) returned to the ED for re-evaluation within 72 hours. CONCLUSIONS: SSE is an efficacious and safe therapeutic option for the acute treatment of childhood fecal impaction in the ED setting.

Prevalence and severity of antipsychotic related constipation in patients with schizophrenia: a retrospective descriptive study.

BACKGROUND: Antipsychotic are the cornerstone in the treatment of schizophrenia. They also have a number of side-effects. Constipation is thought to be common, and a potential serious side-effect, which has received little attention in recent literature. METHOD: We performed a retrospective study in consecutively admitted patients, between 2007 and 2009 and treated with antipsychotic medication, linking different electronic patient data to evaluate the prevalence and severity of constipation in patients with schizophrenia under routine treatment conditions. RESULTS: Over a period of 22 months 36.3% of patients (99) received at least once a pharmacological treatment for constipation. On average medication for constipation was prescribed for 273 days. Severe cases (N = 50), non-responsive to initial treatment, got a plain x-ray of the abdomen. In 68.4% fecal impaction was found. CONCLUSION: A high prevalence of constipation, often severe and needing medical interventions, was confirmed during the study period. Early detection, monitoring over treatment and early intervention of constipation could prevent serious consequences such as ileus.

Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG.

OBJECTIVE: We hypothesized that enemas and polyethylene glycol (PEG) would be equally effective in treating rectal fecal impaction (RFI) but enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction. METHODS: Children (4-16 years) with functional constipation and RFI participated. One week before disimpaction, a rectal examination was performed, symptoms of constipation were recorded, and the first CTT measurement was started. If RFI was determined, then patients were assigned randomly to receive enemas once daily or PEG (1.5 g/kg per day) for 6 consecutive days. During this period, the second CTT measurement was started and a child's behavior questionnaire was administered. Successful rectal disimpaction, defecation and fecal incontinence frequencies, occurrence of abdominal pain and watery stools, CTTs (before and after disimpaction), and behavior scores were assessed. RESULTS: Ninety-five patients were eligible, of whom 90 participated (male, n = 60; mean age: 7.5 +/- 2.8 years). Forty-six patients received enemas and 44 PEG, with 5 dropouts in each group. Successful disimpaction was achieved with enemas (80%) and PEG (68%; P = .28). Fecal incontinence and watery stools were reported more frequently with PEG (P < .01), but defecation frequency (P = .64), abdominal pain (P = .33), and behavior scores were comparable between groups. CTT normalized equally (P = .85) in the 2 groups. CONCLUSION: Enemas and PEG were equally effective in treating RFI in children. Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI.

[Suspected free air--a case report of a patient with a huge fecaloma].

Abdominal free air upon X-ray examination implies a medical emergency, but there is an extensive differential diagnosis that should be considered. Fecaloma is one of the possible imitators of free abdominal air. Fecaloma is a complication of chronic constipation, in which a large fecal mass impacts the bowel, imitating a tumor mass. This phenomenon is not uncommon in the elderly, and requires prompt recognition and immediate medical treatment. A 29-year-old woman, known to suffer from mental retardation, was admitted due to frequent vomiting and diarrhea following constipation a few days prior to her admission. The patient was treated in her institution by an enema, with partial decompression, that was followed by recurrent vomiting and fever. Physical examination upon admittance revealed a distended abdomen without peritoneal signs. An abdominal X-ray series demonstrated a distended large bowel with an abundance of fecal contents, and suspected free air in the abdominal cavity. Due to these findings, an abdominal CT was performed, which demonstrated a huge fecaloma involving the descending and sigmoid colon. The patient was treated non-operatively with: IV fluids, oral laxatives, frequent enemas and manual stool disimpaction. Following this treatment the patient's condition improved dramatically. Fecaloma is a situation that requires prompt recognition and treatment. The diagnosis of fecaloma is a clinical challenge. In addition to signs, symptoms and physical examination, which may be non-specific, the use of X-rays, CT and US may aid in the diagnosis. The treatment in most cases consists primarily of hydration, laxatives, enemas and manual disimpaction. If there is no improvement, one should consider endoscopic treatment, or surgery which may entail a partial or total colectomy.

Hepatic derangement following N-Acetylcysteine enemas in an infant with cystic fibrosis.

We discuss an infant with MI secondary to cystic fibrosis, who was managed surgically by a double barrel ileostomy for mid - small bowel atresia and developed severe faecal impaction in the post - operative period. The faecal impaction was treated successfully with oral NAC and 0.2% NAC contrast enemas. The patient's liver function tests revealed a dramatic increase in transaminases and bilirubin contemporaneous with the administration of the enemas. The levels showed a spontaneous improvement after discontinuation. This is only the second reported case of hepatotoxicity secondary to NAC enemas in the literature. While our experience offers modest support for the use of NAC, its efficacy is not yet proven and paediatric surgeons using NAC in the enema form need to closely monitor liver function contemporaneous with this agent's administration and adjust their treatment accordingly.

Outcome of medical and surgical treatment of cecal impaction in horses: 114 cases (1994-2004).

OBJECTIVE: To determine short- and long-term outcomes, including recurrence rates, for horses with cecal impaction treated medically or surgically. DESIGN: Retrospective case series. ANIMALS: 114 horses. PROCEDURES: Medical records were reviewed for information on signalment, history, clinical findings, treatment (medical vs surgical), and short-term outcome. Information on longterm outcome was obtained through a mail survey and telephone interview with owners. RESULTS: 54 horses were treated medically, 49 horses were treated surgically, and 11 horses were euthanized after initial examination without further treatment. Horses treated surgically were significantly more likely to have signs of moderate or severe pain than were horses treated medically. Forty-four of the 54 (81%) horses treated medically were discharged from the hospital. Twelve of the 49 horses treated surgically were euthanized at surgery because of cecal rupture. Thirty-five of the 37 (95%) horses that were allowed to recover from surgery were discharged from the hospital. In 34 horses treated surgically, typhlotomy without a bypass procedure was performed. Long-term (>or= 1 year) follow-up information was available for 19 horses treated medically and 28 horses treated surgically. Eighteen (95%) and 25 (89%) of the horses, respectively, were alive at least 1 year after treatment. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that medical and surgical treatment were both associated with favorable outcomes in horses with cecal impactions. In this population, typhlotomy alone without cecal bypass was associated with a low recurrence rate. The long-term prognosis for horses that were discharged from the hospital was good.

Clinical and economic impact of using macrogol 3350 plus electrolytes in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction based on actual clinical practice in England and Wales.

OBJECTIVE: To estimate the clinical and economic impact of using macrogol 3350 plus electrolytes (macrogol 3350; Movicol; Movicol Paediatric Plain) in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction. METHODS: A chart review was undertaken to extract clinical outcomes and resource use from the case notes of a cohort of children aged 2-11 years with faecal impaction who initially received either macrogol 3350 (in an outpatient setting) or enemas and suppositories or manual evacuation for initial disimpaction. Five centres across England and Wales participated in the study. These data were used to inform a decision model which depicted the management of children during the disimpaction phase and for a period of 12 weeks following initial disimpaction. Unit resource costs at 2005/2006 prices were applied to the resource utilisation estimates within the model, enabling the incremental costs and consequences of using macrogol 3350 in an outpatient setting, compared to the other treatments, to be estimated. RESULTS: 112 patients treated with macrogol 3350, 101 who received enemas and suppositories and 11 who underwent a manual evacuation were eligible for analysis. Ninety-seven per cent of children treated with macrogol 3350 were successfully disimpacted within 5 days, compared to 73% of those who received enemas and suppositories and 89% of those who underwent a manual evacuation (p < 0.001). There were no significant differences in reported adverse events between the different treatments for disimpaction, with the exception of vomiting which was significantly higher among those who underwent a manual evacuation (18% versus 2% with the other treatments; p < 0.01). There were no significant differences in the number of clinician outpatient visits between treatments. However, macrogol 3350-treated patients had significantly fewer hospital admissions than those who received the other interventions (0.1 versus 1.4 and 1.0 for enemas and suppositories and manual evacuation respectively; p < 0.05) and occupied fewer bed days. The total NHS cost of disimpaction and subsequent maintenance of children initially treated with macrogol 3350 was estimated to be 694 pounds sterling (95% CI: 496 pounds sterling; 892 pounds sterling). This compared with 2759 pounds sterling (95% CI: 1266 pounds sterling; 4252 pounds sterling) and 2333 pounds sterling (95% CI: 1609 pounds sterling; 3058 pounds sterling) for those who initially received enemas and suppositories or underwent a manual evacuation, respectively. Hence, using macrogol 3350 instead of enemas and suppositories and manual evacuation to disimpact the whole annual cohort of faecally impacted children aged 2-11 years in England could potentially reduce annual NHS expenditure on this condition by 59% (5 million pounds sterling) and reduce the annual number of paediatric hospital admissions for this condition by 92% (4330). CONCLUSION: Within the limitations of our model, macrogol 3350 affords the NHS a clinically effective and cost-effective treatment for the disimpaction of children suffering from faecal impaction compared to enemas and suppositories or a manual evacuation, and has the potential to release healthcare resources for alternative use within the system.

Modelling the costs and consequences of treating paediatric faecal impaction in Australia.

OBJECTIVE: To compare the costs and consequences of using oral macrogol 3350 plus electrolytes (macrogol 3350; Movicol) compared to enemas/suppositories, manual evacuation and naso-gastric administration of macrogol (NGA-PEG) lavage solution in treating paediatric faecal impaction in Australia. METHOD: A decision model was constructed using published clinical outcomes, utilities and clinician-derived resource utilisation estimates. The model was used to determine the expected Commonwealth and parent costs associated with each treatment over the period of disimpaction and 12 weeks post-disimpaction, in Australian dollars at 2003/2004 prices. RESULTS: 92% of oral macrogol 3350-treated patients are expected to be disimpacted within 6 days following initial treatment, compared with 79% of patients treated with enemas and suppositories who are expected to be disimpacted within 8 days. All patients are expected to be disimpacted within 5 days following a manual evacuation and within 2 days following NGA-PEG. The level of health gain at 12 weeks post-disimpaction irrespective of treatment for disimpaction and subsequent maintenance is expected to be the same; the expected quality-adjusted life years (QALYs) being 0.20 (95% CI: 0.17; 0.23). Starting treatment with oral macrogol 3350 in an outpatient setting is expected to lead to a Commonwealth cost of $758, compared to $1838 with NGA-PEG, $2125 with enemas and suppositories, $3931 with oral macrogol 3350 in an inpatient setting and $4478 with manual evacuation. Resource use associated with maintenance following initial disimpaction is expected to be broadly similar, irrespective of initial laxative. Hence, the expected Commonwealth cost is primarily affected by the treatment used to initially disimpact a patient. Expected parents' costs are expected to be comparable irrespective of treatment ranging from $89 to $112 per patient. CONCLUSION: Within the limitations of our model, using oral macrogol 3350 in an outpatient setting for treating faecally impacted children affords a cost effective alternative compared to the other treatments investigated.

Management of functional constipation in childhood.

Functional constipation is a common condition. In the majority of cases the constipation develops as a result of a complex weave of factors including specific triggers, e.g. reduced fluid intake following a viral infection or periods of restricted access to the toilet. The passage of large painful stools perpetuates the problem when the child begins to associate pain with defecation. The management of constipation can often be a challenge in children, who initially may be reluctant to sit on the toilet. This article will discuss the contributory factors to the cause of constipation and identify the keys to successful treatment, including ensuring a holistic child-focused approach with effective initial evacuation and appropriate maintenance therapy.

Golytely: a new approach to faecal impaction in old age.

Forty-five elderly subjects with faecal impaction were entered into a study of the efficacy of golytely. Twenty-three were treated with golytely 2 l/day for 2 days and then lactulose 30 ml b.d. and daily enemas. Twenty-two were treated with lactulose 30 ml b.d. and daily enemas alone. A good response was achieved in 13 (56%) within 1 week and in 20 (87%) within 2 weeks when golytely was used, as compared to only 5 (23%) within 1 week and 9 (41%) within 2 weeks when it was not used.

Profound shock following intervention for chronic untreated stool retention. A case report.

Chronic stool retention with soiling is a common and distressing condition in children. Diagnosis and treatment generally involve both medical and psychological aspects. This case addresses a potentially life-threatening complication of shock occurring during treatment of chronic stool retention with castor oil, and also explores the psychosocial factors felt to be contributory.