The protocol for Constipation/Fecal Impaction:Constipation
Let’s break it down!
Constipation is an extremely common occurrence, affecting 19% of the US population at any given moment. The exact definition of constipation varies from person-to-person, but commonly used criteria involve at least 2 of the following within a 6-month time frame:
- 2 or fewer bowel movements per week
- Straining >25% of the time
- Hard stools >25% of the time or incomplete evacuation >25% of the time.
Any changes in lifestyle or diet (particularly a lack of fiber) can cause someone to suffer from constipation. With the constant changing of environments and extreme inconsistency of diet, this is a particularly common problem in the military. The following video explains how exactly constipation occurs:
If prolonged constipation leads to a massive buildup of stool and causes a bowel obstruction, this is considered a fecal impaction. Although it’s not usually life-threatening, it can be extremely uncomfortable and potentially lead to gastrointestinal complications if not removed within a reasonable time frame.
Constipation isn’t particularly difficult to diagnose. Soldiers are typically aware of changes in their bowel movement pattern and are happy to tell you all about it. As stool builds up, patients will have a general feeling of fullness and will typically be unable to pinpoint where exactly they feel pain, if they feel it at all. Fecal impaction can reasonably be suspected when the pain becomes severe or when the patient is unable to pass any foods, liquids, or gas through the bowel. Below is an image showing fecal impactions circled in an abdominal X-ray:
These are typically the first steps to take for anybody suffering from constipation:
1. Increase PO fluids and fiber — fruits, bran, vegetables
Diet change is the least invasive way to treat constipation. An increase in fiber consumption is beneficial because fiber cannot be absorbed by the GI tract and helps to provide the bulk for the creation of stools. A lack of fiber can contribute to the formation of small, hard stools and subsequent difficulty in having a bowel movement. Drinking water will also provide moisture and soften the stools.
2. Bisacodyl (Dulcolax) 10mg PO tid prn
Bisacodyl is a stimulant laxative that works by stimulating enteric nerves that cause peristalsis, which is the contractions in the colon that help move feces along. After ingesting, it typically produces a bowel movement within 6 to 12 hours. Like any laxative, it should be used with caution to avoid diarrhea or laxative dependency. Most doctors typically don’t recommend taking this for longer than a week at a time.
3. Treat per Pain Management protocol (no narcotics — they cause constipation!)
For a mild case of constipation, pain medications aren’t usually necessary. However, fecal impaction can lead to pretty remarkable pain that may require the use of Tylenol or NSAIDs. We want to avoid any opiate medications because they are notorious for slowing down peristalsis, which is highly unproductive for these patients.
For our fecal impaction patients, more invasive measures are going to be required. The first go-to intervention will be a rectal enema, which entails infusing about 500cc of normal saline in the rectum to help loosen the stool. After about 2 minutes following the infusion, the patient should feel the urge to defecate and with luck, it’ll be loose enough to pass through. There are various ways to accomplish a rectal enema, but the easiest way for us is to just use a regular bag of saline w/ lubricated IV tubing. The video below shows how to give a child a rectal enema using slightly different equipment, but the basic principle is still there:
If the rectal enema fails, the next step is to manually check for a fecal impaction to ensure that we’re not missing something else. If it is indeed a stubborn fecal mass, then a digital disempaction is warranted. The video below shows how to perform it:
**For these procedures above, always be sure to have a witness or chaperone with you for the protection of both you and the patient.
The symptoms above contradict that of constipation. Things like severe pain, rigid abdomen, fever, rebound tenderness, or large quantities of blood in the stool tend to represent more sinister abdominal etiologies like appendicitis, diverticulitis, perforated ulcers, etc. These conditions would best be managed under the Abdominal Pain protocol.
Evacuation is seldom required for these patients. Fluids, fiber, and laxatives can solve most cases. Stubborn fecal impactions warrant Routine evacuations if rare measures are needed, like surgery. Urgent evacuation for the sinister abdominal etiologies that can cause the patient to become septic and rapidly decline.
Good luck out there!
- Sommers T, Corban C, Sengupta N, et al. Emergency department burden of constipation in the United States from 2006 to 2011. Am J Gastroenterol. 2015;110(4):572–579. doi:10.1038/ajg.2015.64
- EMRAP Corependium: Constipation
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.