TITLE: Enemas for the Treatment of Constipation in the Emergency Department:
Clinical Effectiveness and Guidelines
DATE:
23 February 2015
RESEARCH QUESTIONS
1.
What is the clinical effectiveness and harms of enemas for patients presenting with
constipation and fecal impaction in the emergency department?
2.
What are the evidence-based guidelines regarding the use of enemas for patients
presenting with constipation and fecal impaction in the emergency department?
KEY FINDINGS
One randomized controlled trial, three non-randomized studies, and one evidence-based
guideline were identified regarding the use of enemas for patients presenting with constipation
and fecal impaction in the emergency department.
METHODS
A limited literature search was conducted on key resources including PubMed, The Cochrane
Library (2015, Issue 2), University of York Centre for Reviews and Dissemination (CRD)
databases, Canadian and major international health technology agencies, as well as a focused
Internet search. No filters were applied to limit the retrieval by study type. Where possible,
retrieval was limited to the human population. The search was also limited to English language
documents published between January 1, 2010 and February 6, 2015. Internet links were
provided, where available.
The summary of findings was prepared from the abstracts of the relevant information. Please
note that data contained in abstracts may not always be an accurate reflection of the data
contained within the full article.
Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in
Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to
provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time
allowed. Rapid responses should be considered along with other types of information and health care considerations. The
information included in this response is not intended to replace professional medical advice, nor should it be construed as a
recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality
evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for
which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation
of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect.
CADTH is not liable for any loss or damages resulting from use of the information in the report.
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SELECTION CRITERIA
One reviewer screened citations and selected studies based on the inclusion criteria presented
in Table 1.
Table 1: Selection Criteria
Population
Intervention
Comparator
Outcomes
Study Designs
Patients presenting with constipation and fecal impaction in the emergency
department
Enema (any type)
Any comparator (e.g., placebo, other management methods, enemas
compared with each other)
Clinical benefit (e.g., changes in bowel function), clinical harm
Guidelines
Health technology assessments, systematic reviews, meta-analyses,
randomized controlled trials, non-randomized studies, evidence-based
guidelines
RESULTS
Rapid Response reports are organized so that the higher quality evidence is presented first.
Therefore, health technology assessment reports, systematic reviews, and meta-analyses are
presented first. These are followed by randomized controlled trials, non-randomized studies,
and evidence-based guidelines.
One randomized controlled trial (RCT), three non-randomized studies, and one evidence-based
guideline were identified regarding the use of enemas for patients presenting with constipation
and fecal impaction in the emergency department (ED). No relevant health technology
assessment reports, systematic reviews, or meta-analyses were identified.
Additional references of potential interest are provided in the appendix.
OVERALL SUMMARY OF FINDINGS
One RCT,1 three non-randomized studies,2-4 and one evidence-based guideline5 were identified
regarding the use of enemas for patients presenting with constipation and fecal impaction in the
ED. All identified references were relevant to a pediatric population.
The RCT1 evaluated the comparative clinical effectiveness of enema versus polyethylene glycol
(PEG) 3350 for the treatment of fecal impaction in children. This study demonstrated that
patients who had received an enema had significantly improved symptoms relative to PEG
within three days of administration but that there was no difference between treatment groups
on the fifth day post-treatment.1 The results of one retrospective cohort study2 of pediatric ED
constipation cases showed that children who received an enema were significantly more likely
to revisit the ED than those who did not.
Two non-randomized studies3,4 examined the clinical effectiveness and safety of the milk and
molasses enema. One retrospective chart review3 of pediatric patients presenting to the ED with
constipation or abdominal pain revealed that the majority of patients treated with a milk and
molasses enema experienced relief from constipation, and that the success rate was associated
with patient age and enema volume. The authors added that the enemas had minimal side
Enemas for the Treatment of Constipation in the Emergency Department
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effects.3 Another study showed that there were no significant differences in patient outcomes
between milk and molasses enemas and sodium phosphate enemas for the treatment of
pediatric constipation.4
In a National Institute for Health and Clinical Excellence (NICE) guideline for the management of
pediatric constipation in primary and secondary care,5 enemas are not recommended for firstline treatment of fecal disimpaction but are listed as an option for cases in which all oral
medications have failed. Recent evidence of the similar clinical effectiveness of oral laxatives
and enemas for fecal disimpaction that was cited in the guideline update has not altered this
recommendation.5
Enemas for the Treatment of Constipation in the Emergency Department
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REFERENCES SUMMARIZED
Health Technology Assessments
No literature identified.
Systematic Reviews and Meta-analyses
No literature identified.
Randomized Controlled Trials
1.
Miller MK, Dowd MD, Friesen CA, Walsh-Kelly CM. A randomized trial of enema versus
polyethylene glycol 3350 for fecal disimpaction in children presenting to an emergency
department. Pediatr Emerg Care. 2012 Feb;28(2):115-9.
PubMed: PM22270500
Non-Randomized Studies
2.
Freedman SB, Thull-Freedman J, Rumantir M, Eltorki M, Schuh S. Pediatric constipation
in the emergency department: evaluation, treatment, and outcomes. J Pediatr
Gastroenterol Nutr. 2014 Sep;59(3):327-33.
PubMed: PM24796805
3.
Wallaker K, Fortuna E, Bradin S, Macy M, Hassan M, Stanley R. Milk and molasses
enemas: clearing things up. J Emerg Nurs. 2014 Nov;40(6):546-51.
PubMed: PM24182894
4.
Hansen SE, Whitehill JL, Goto CS, Quintero CA, Darling BE, Davis J. Safety and efficacy
of milk and molasses enemas compared with sodium phosphate enemas for the treatment
of constipation in a pediatric emergency department. Pediatr Emerg Care. 2011
Dec;27(12):1118-20.
PubMed: PM22134228
Guidelines and Recommendations
5.
Constipation in children and young people: evidence update June 2012 [Internet]. London
(UK): National Institute for Health and Clinical Excellence (NICE); 2012 Jun [cited 2015
Feb 19]. Available from:
http://www.nice.org.uk/guidance/cg99/evidence/cg99-constipation-in-children-and-youngpeople-evidence-update2
See: Faecal disimpaction, page 7
PREPARED BY:
Canadian Agency for Drugs and Technologies in Health
Tel: 1-866-898-8439
www.cadth.ca
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APPENDIX – FURTHER INFORMATION:
Systematic Reviews and Meta-analyses – Unclear Setting
6.
Tabbers MM, Boluyt N, Berger MY, Benninga MA. Constipation in children. BMJ Clin Evid
[Internet]. 2010 Apr 6 [cited 2015 Feb 12];2010. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907595
PubMed: PM21718570
Non-Randomized Studies – Alternate Comparator
7.
Niv G, Grinberg T, Dickman R, Wasserberg N, Niv Y. Perforation and mortality after
cleansing enema for acute constipation are not rare but are preventable. Int J Gen Med
[Internet]. 2013 Apr 26 [cited 2015 Feb 12];6:323-8. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641812
PubMed: PM23658492
Guidelines and Recommendations
Unclear or Alternate Setting
8.
Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al.
Evaluation and treatment of functional constipation in infants and children: evidencebased recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr
[Internet]. 2014 Feb [cited 2015 Feb 12];58(2):258-74. Available from:
http://www.naspghan.org//files/documents/pdfs/positionpapers/Constipation_Feb_2014.pdf
PubMed: PM24345831
See: 7.1 'kenlambon@bellnet.ca'Which Pharmacologic Treatment Should Be Given for
Disimpaction? page 269
Recommendation 32, page 269
9.
American Gastroenterological Association, Bharucha AE, Dorn SD, Lembo A, Pressman
A. American Gastroenterological Association medical position statement on constipation.
Gastroenterology. 2013 Jan;144(1):211-7.
PubMed: PM23261064
Summarized at: http://www.guideline.gov/content.aspx?id=43610
See: What Approaches Should Be Considered for Constipation Unresponsive to Initial
Approaches?
Unclear Methodology
10.
Constipation: emergency department clinical guidelines [Internet]. Perth (AU): Princess
Margaret Hospital for Children; 2012 [cited 2015 Feb 18]. Available from:
http://kidshealthwa.com/wp-content/uploads/2013/06/constipation-guideline-201206.pdf
See: Treatment of Acute Constipation, page 4
Treatment of Chronic Retentive Constipation (Disimpaction), page 4
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11.
Tait A. Constipation: Starship Children’s Health clinical guideline [Internet]. Auckland (NZ):
Starship Children’s Health; 2012 Feb [cited 2015 Feb 18]. Available from:
http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Constipation.pdf
See: Phosphate enemas (Age >3 yrs), page 3
12.
Functional constipation and soiling in children [Internet]. Ann Arbor (MI): University of
Michigan Faculty Group Practice, Quality Management Program; 2008 [revised 2012;
cited 2015 Feb 18]. Available from:
http://www.med.umich.edu/1info/FHP/practiceguides/newconstipation/peds08.pdf
See: Table 7 – Cleanout in emergency department or inpatient setting, page 7
13.
The Royal Children’s Hospital Melbourne [Internet]. Melbourne (AU): Royal Children’s
Hospital Melbourne; [date unknown]. Constipation; [cited 2015 Feb 20]. Available from:
http://www.rch.org.au/clinicalguide/guideline_index/Constipation_Guideline/
See: Management, Disimpaction (for severe symptoms)
Additional References
Safety
14.
Sodium phosphate/sodium biphosphate, enema. Safety considerations [Internet].
Washington (DC): VA Pharmacy Benefits Management Services, Medical Advisory Panel,
VISN Pharmacist Executives; 2013 Jul [cited 2015 Feb 19]. Available from:
http://www.pbm.va.gov/PBM/clinicalguidance/clinicalrecommendations/Sodium_Phosphat
e_Sodium_Biphosphate_Enema_Safety_Considerations.pdf
15.
Patient matters manual for public health organisations [Internet]. North Sydney (AU): NSW
Government Health; [updated 2012]. Chapter 15, Nursing; [cited 2015 Feb 19]. p. 15.115.29. Available from:
http://www.health.nsw.gov.au/policies/manuals/Documents/pmm-15.pdf
See: Administration of Disposable Enemas – Danger from Excessive Pressure, pages
15.3-15.4
Case Study
16.
Gu MM, Gonzalez CE, Todd KH. Emergent management of constipation in cancer
patients. Emergency Medicine [Internet]. 2011 Nov [cited 2015 Feb 18]:6-12. Available
from: http://www.emed-journal.com/fileadmin/qhi_archive/ArticlePDF/EM/043110006.pdf
See: Figure 3. Algorithm for Treating Constipation in Cancer Patients in the ED, page 10
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