Bowel Management in Hospital & Community Settings

Affects 40–95% of opioid users. Prophylactic laxative must be prescribed with every opioid.

• First line: Senna ± macrogol — start with opioid initiation
• Avoid: Bulk-forming agents alone (may worsen if insufficient fluid)
• Methylnaltrexone (Relistor): SC injection — peripheral opioid receptor antagonist; use if oral laxatives fail; does not reverse CNS analgesia; dose by weight (8–12 mg SC EOD)
• Naloxegol (Movantik): PO 25 mg OD — PAMORA; stop 3 days before surgery
• Naldemedine (Symproic): PO 0.2 mg OD; newer PAMORA option
• Review opioid dose reduction if clinically possible
• Assess every 48 hours in inpatients on opioids

• Expected 3–5 days after abdominal surgery
• Signs: absent bowel sounds, distension, nausea, no flatus/stool
• ERAS (Enhanced Recovery): early mobilisation, early oral intake, minimise opioids, alvimopan (if available)
• Avoid prolonged NBM; encourage early oral fluids
• Chewing gum 3× daily post-op may stimulate motility
• NG tube if distension / vomiting significant
• Monitor urine output, electrolytes (K⁺ especially)
• Escalate if >5 days with worsening distension — exclude obstruction

1. Explain procedure to patient; ensure privacy
2. Patient passes stool into a clean bedpan or collection hat
3. Use a sterile specimen container with spoon lid
4. Collect ≈5–10 mL (walnut-sized) sample
5. Label immediately: patient name, DOB, date/time, MRN
6. Specify test required: MC&S, C. diff toxin PCR, OVA/parasites, virology
7. Transport to lab within 2 hours (or refrigerate max 24 h)
8. Do not collect from nappy/pad if possible
9. Collect before starting antibiotics where possible
10. Document collection; record stool frequency on fluid chart

• ORS (WHO formula): glucose 75 mmol/L, Na 75 mmol/L, Cl 65 mmol/L, K 20 mmol/L — 200 mL after each loose stool
• Adults: minimum 2–3 L/day; increase with each liquid stool
• Monitor urine output; target ≥0.5 mL/kg/hr
• IV fluids if oral intake insufficient, vomiting, or haemodynamically compromised
• Electrolyte monitoring: Na, K, Mg, Cl, bicarbonate
• Weigh daily in hospitalised patients
• BRAT diet (banana, rice, applesauce, toast) — supportive, not evidence-based but well tolerated
• Avoid dairy, caffeine, alcohol during acute diarrhoea
• Probiotics (Lactobacillus, Saccharomyces boulardii) may reduce antibiotic-associated diarrhoea duration

1. Perform 20–30 minutes after a meal (gastrocolic reflex)
2. Position: sitting on toilet or commode if possible; left lateral if not
3. Apply lubricant generously to gloved index finger
4. Insert finger 2–3 cm into rectum; move in gentle circular motion for 15–20 seconds
5. Pause 1–2 minutes; repeat until stool passes or no further response
6. Maximum 3 cycles; stop if patient becomes dysreflexic (SCI above T6)
7. Autonomic dysreflexia signs: severe headache, flushing, sweating, bradycardia — sit patient upright, remove cause, call emergency if BP >150 systolic
8. Document timing, stool amount, patient tolerance

• Indications: neurogenic bowel (SCI, MS, myelomeningocele), slow-transit constipation, faecal incontinence unresponsive to conservative management
• Contraindications: active colitis, colorectal cancer, recent rectal surgery, diverticulitis, anal stenosis, pregnancy
• Systems: Peristeen, Navina, Irrimatic — rectal catheter balloon inflated with water
• Volume: start 200–500 mL warm water; titrate to 500–1500 mL
• Frequency: every 1–2 days; same time each day (after breakfast)
• Training: 3–5 supervised sessions before independent use
• Complications: autonomic dysreflexia, bowel perforation (rare), vasovagal, abdominal cramps
• Evidence: significantly improves QoL and reduces constipation/incontinence in SCI (Level A evidence)

Colostomy

• Normal output: formed/semi-formed; 1–2×/day
• Consistency depends on stoma site: sigmoid = firm; transverse = soft/pasty
• High output (>1000 mL/day): dehydration risk; review diet, anti-motility agents
• Record in stoma output chart: frequency, consistency, colour, odour, blood
• Skin barrier paste / wafer — change every 3–5 days or if leaking

Ileostomy

• Normal output: 600–800 mL/day (liquid–porridge consistency)
• High output (>1500 mL/day): risk of dehydration, Na/Mg depletion
• Treat high output: loperamide, codeine (if appropriate), dietary modification
• Pancaking (stool sits at bag top): add lubricant, vent bag
• Bowel diary: include fluid intake, diet, output volume

• Footstool: raise feet 7–23 cm; lean forward 35° from hips
• Elbows resting on knees; do not hold breath
• Allow 10–15 minutes undisturbed; use call bell
• Respond to natural urge; avoid ignoring defaecation urge
• Optimise privacy — essential in GCC hospital settings
• Consider commode at bedside if mobility impaired
• Avoid bedpan if possible — impairs pelvic floor relaxation

Document for minimum 7 days for pattern assessment.

Score 0 (perfect continence) to 20 (complete incontinence). Score ≥9 indicates significant impact on quality of life.

• DRE: assess resting tone, squeeze pressure, length of squeeze
• Anorectal manometry: gold standard for sphincter pressures; rectal sensation, compliance
• Endoanal ultrasound: structural sphincter defects (obstetric injury, previous surgery)
• MRI pelvis: complex fistula, levator damage
• Pudendal nerve latency: if neurogenic aetiology suspected
• Colonoscopy/sigmoidoscopy: if red flags, IBD, neoplasia

Refer to Colorectal/Continence Clinic if:

• Wexner score ≥9
• Failed conservative management >6 weeks
• Suspected structural sphincter defect
• Significant psychological impact
• Post-obstetric or post-surgical FI

• Constipation risk increases: reduced daytime fluid/fibre intake, altered meal timing
• Bowel habit shift: main meals at Iftar and Suhoor — defaecation pattern shifts to morning/night
• Medication timing: reschedule laxatives to Iftar and Suhoor; coordinate with pharmacist
• Suppositories/enemas: scholarly consensus — generally permitted for medical necessity; discuss with patient's religious authority if concerned
• Hydration: encourage ≥2 L fluid between Iftar and Suhoor; ORS at Iftar if diarrhoea
• Fibre intake: encourage dates (natural laxative), vegetables at Iftar; avoid excessive refined carbohydrates
• Patients with uncontrolled diarrhoea, severe constipation, or stoma issues: medically exempt from fasting — advise accordingly with sensitivity
• Document patient's fasting status on medication chart

• Gelatin capsules: most are porcine-derived; not halal. Options: seek alternative tablet/liquid form; use bovine gelatin (check manufacturer); seek pharmacist alternative
• Lactulose: generally halal; check if produced via fermentation or animal-derived enzyme
• Some laxatives contain alcohol excipient (syrups) — check formulation; use tablet alternatives if possible
• Enemas/suppositories: may contain lanolin (wool fat) — halal permissible; animal-derived ingredients generally permissible for medical necessity
• IV preparations: generally acceptable for medical necessity
• Principle of Darura (necessity): in Islamic jurisprudence, prohibited substances become permitted when medically necessary and no halal alternative exists
• Document discussion with patient; involve Islamic chaplain/scholar if requested
• GCC hospitals should maintain a halal medication formulary — check DHA/DOH/MOH formulary lists

• GCC summer temperatures 40–50°C; outdoor/construction workers at highest risk
• Fluid losses of 1–1.5 L/hour in extreme heat — stool becomes hard/pellet-like
• Assess: fluid intake history, occupation, duration of heat exposure
• Management: rehydration first — 2–3 L/day minimum; ORS if significant loss
• Osmotic laxatives (macrogol) preferred — work by drawing water into colon
• Avoid stimulant laxatives alone without ensuring adequate hydration
• Community education: mandatory water breaks every 45 minutes for outdoor workers (GCC labour laws)
• Migrant worker populations: communal housing → risk of C. diff / gastroenteritis spread

• Constipation prevalence: 50–74% in nursing home/long-term care
• Causes: reduced mobility, polypharmacy, low fluid intake, low fibre, reduced rectal sensation
• Polypharmacy review: opioids, anticholinergics, calcium channel blockers, iron supplements, antidepressants — all constipating
• Prefer macrogol over lactulose (less gas, better tolerated)
• Avoid stimulant laxatives long-term — risk of melanosis coli, dependence
• Phosphate enemas: high risk in elderly — acute phosphate nephropathy, hypocalcaemia
• Manual evacuation more commonly required; document carefully
• Assess cognition (MMSE) — affects bowel programme compliance
• Timed toileting programme: after breakfast, utilise gastrocolic reflex
• Abdominal massage: 10 minutes daily, clockwise — may reduce laxative use

Bariatric surgery rates in GCC are among the highest globally. Bowel complications are common in this cohort.

• All bariatric patients: avoid NSAID suppositories (anastomosis risk)
• Modified-release/enteric-coated medications may be poorly absorbed post-RYGB — check formulation
• Document weight and nutritional status; refer to bariatric dietitian

• GCC countries have strict controlled drug regulations (DDA laws) — opioids require narcotic prescriptions, witnessed administration, triplicate forms
• Under-prescribing of opioids (fear of addiction, legal consequences) remains a challenge — leads to undertreated pain
• Cancer patients and palliative care: opioid use rising with oncology expansion in GCC
• OIC is universal with regular opioids — prophylactic laxative must be co-prescribed in all cases
• PAMORA agents (methylnaltrexone, naloxegol) may have limited availability/registration in some GCC countries — check local formulary
• Document bowel frequency on all patients receiving opioids; escalate if no BM >3 days
• Post-op opioid use: prescribe senna 15 mg nocte or macrogol 1 sachet daily from day 1 post-op
• Opioid rotation (e.g., switching to fentanyl patch) may reduce OIC compared to oral morphine
• Patient education in Arabic: risks of constipation with opioids; when to contact healthcare team