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Fecal Incontinence: Office-Based Management
Published in Laurence R. Sands, Dana R. Sands, Ambulatory Colorectal Surgery, 2008
Tisha Lunsford, Jonathan Efron
After an appropriate work-up has excluded organic disease, the first step in treatment is the initiation of bulking agents such as psyllium or methylcellulose (Metamucil® or Citrucel®), partially hydrolyzed guar gum (Benefiber®), and previously attapulgite (Kaopectate®). Due to concerns of high lead levels, the makers of Kaopectate have recently reformulated the drug so that its primary ingredient is bismuth salicylate (the primary ingredient in Pepto Bismal®). When using bulking agents, modifying stool consistency is the primary goal because formed stool is much easier to control than loose stool. The formulations of psyllium, methylcellulose and guar gum are available in both powder and tablet form. Tablets, in a recommended dose of one to two tablets twice daily, are preferred in the case of loose or diarrheal stools, as fiber may procure more benefit as a bulking agent when taken with only sips of a noncaffeinated clear beverage. Bismuth salicylate may also be used; however, unlike the fiber formulations, this medication should only be used for temporary relief of symptoms. Pharmacotherapy with agents such as loperamide, diphenoxylate/atropine, alosetron, clonidine, cholestyramine, colestipol, probiotics, tincture of opium, and amytriptyline are usually reserved for patients with more persistent diarrhea that does not respond to conservative bulking agents. Intuitively, the subsequent decreased stool frequency produced by these agents should lessen the frequency of incontinent episodes. Applications and dosing guidelines for the aforementioned pharmacologic agents are outlined in Table 5. However, special concerns may arise in patients with IBS-Diarrhea (IBS-D) predominant as conservative fiber therapy may exacerbate abdominal bloating and discomfort and may precipitate poor compliance. If these bothersome symptoms do not abate after 7 days of use, initiation of pharmacotherapy, including loperamide, amytriptyline, probiotics (specifically those that contain Bifidobacterium), alosetron (limited to certified prescribers), or cilansetron (currently in phase III clinical development), may provide more effective relief for the subset of patients with IBS-D (11–17).
Is there a role for charcoal in palliative diarrhea management?
Published in Current Medical Research and Opinion, 2018
Helen Senderovich, Megan J. Vierhout
Although activated charcoal is not an obvious first line treatment for diarrhea management, another of its positive aspects is negligible side-effects5,23,24. Mrs X, Mr Y, and Mr Z were given charcoal as a second or third line treatment after failure of cholesteramine, loperamide, and octreotide, or risk associated with side-effects of these medications. There is a possibility for the onset of constipation25; however, this is unlikely in patients suffering from diarrhea. There are no known adverse effects or complications as compared to other diarrhea medications. As seen with our three case vignettes, no side-effects were experienced as a result of charcoal treatment. Commonly utilized loperamide may produce fatal side-effects, including serious cardiac consequences26, and inflammation or even perforation of both the small intestine and colon, especially when C. difficile colitis is a concern or may be suspected27,28. After long-term use of loperamide, Mrs X may have been experiencing some of these side-effects without being aware. Potential intestinal inflammation may have been further contributing to her diarrhea. In addition, Loperamide may worsen abdominal cramping and should not be used if there is bloody diarrhea. It should only be used in patients with painless diarrhea, as Loperamide was found to be no more effective than placebo at reducing pain and bloating29,30. Bismuth salicylate, for example, is another alternative, but it can cause delirium, psychosis, ataxia, myoclonus, and seizures31. Therefore, the safety of activated charcoal can be well-appreciated.