Constipation: Difference between revisions
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==Differential Diagnosis == | ==Differential Diagnosis == | ||
===Acute === | ===Acute === | ||
*[[Bowel obstruction]] | |||
**Tumor, stricture, [[hernia]], adhesion, [[volvulus]], [[fecal impaction]] | |||
*New medicine | |||
**[[Opiods]], antipsychotic, [[anticholinergics]], antacid, [[antihistamines]] | |||
*Change in exercise | |||
*Change in diet | |||
*Pain rectal conditions (e.g. [[anal fissure]], [[hemorrhoids]]) | |||
===Chronic === | ===Chronic === | ||
*Acute causes | |||
*[[Hypothyroidism ]] | |||
*Electrolytes | |||
**[[Hypomagnesia]] | |||
**[[Hypercalcemia]] | |||
*[[Hypokalemia]] | |||
==Work-Up == | ==Work-Up == | ||
*Rectal exam | |||
*Guaiac | |||
*Chemistry (hypoK or hyperCa) | |||
*Acute abdominal series (if suspect obstruction) | |||
*TSH | |||
==Treatment == | ==Treatment == | ||
*Stress adequate fluid (1.5L per day), fiber (10gm per day), and exercise | |||
*Meds | |||
**Fiber | |||
***Bran: 1 cup daily | |||
***[[Psyllium]] (Metamucil): 1 teaspoon TID | |||
**Emollient | |||
***[[Docusate]] (Colace): 100mg QD-BID (facilitates mixture of stool fat and water) | |||
***Mineral oil (long term use causes malabsorption) | |||
**Stimulants | |||
***[[Bisacodyl]] (Dulcolax): 10mg PR TID | |||
***[[Senna]]: Two tab PO QD-BID | |||
**Saline laxative | |||
***Milk of mangesia: 15-30 mL QD-BID | |||
***Magnesium citrate: 100-240 mL QD-BID | |||
**Hyperosmolar agents | |||
***[[Lactulose]] 15-30 mL QD-BID | |||
***Polyethylene glycol: 1 gallon/4h | |||
***Miralax: 17gm | |||
***Glycerin: 1 adult suppository PR, onset of action 15-30 min, then 1-2 doses per day | |||
**Enemas | |||
***Soap suds, saline, tap water enema (rectal distention, causing evacuation)<ref>Portalatin M and Winstead N. Medical Management of Constipation. Clin Colon Rectal Surg. 2012 Mar; 25(1): 12–19.</ref> | |||
***May add 50-100 mg of docusate liquid to saline or water enema | |||
***Fleet Phospho-soda: 118 ml single enema dose, with maximum of x2 doses at least 1 hr apart | |||
****No more than 2 doses in a 24 hr period may be administered without serum phos, mag, calcium levels<ref>Farah R. Fatal acute sodium phosphate enemas intoxication. Acta Gastroenterol Belg. 2005 Jul-Sep;68(3):392-3.</ref> | |||
****May observe hyperphosphatemia, hypocalcemia, hypomagnesemia | |||
****High risk pts: renal impairement, abnl gut motility, IBD, elderly, cardiac co-morbidities<ref>Reedy JC, Zwiren GT. Enema-induced hypocalcemia and hyperphosphatemia leading to cardiac arrest during induction of anesthesia in an outpatient surgery center. Anesthesiology. 1983 Dec;59(6):578-9.</ref><ref>Korzets A, Dicker D, Chaimoff C, Zevin D. Life-threatening hyperphosphatemia and hypocalcemic tetany following the use of fleet enemas. J Am Geriatr Soc. 1992 Jun;40(6):620-1.</ref> | |||
==See Also== | ==See Also== | ||
*[[Constipation ( | *[[Constipation (peds)]] | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 11:54, 30 July 2016
Background
- Acute constipation is intestinal obstruction until proven otherwise
- Red flags:
- Weight loss
- Rectal bleeding/melena
- Nausea/vomiting
- Fever
- Rectal pain
- Change in stool caliber
Differential Diagnosis
Acute
- Bowel obstruction
- Tumor, stricture, hernia, adhesion, volvulus, fecal impaction
- New medicine
- Opiods, antipsychotic, anticholinergics, antacid, antihistamines
- Change in exercise
- Change in diet
- Pain rectal conditions (e.g. anal fissure, hemorrhoids)
Chronic
- Acute causes
- Hypothyroidism
- Electrolytes
- Hypokalemia
Work-Up
- Rectal exam
- Guaiac
- Chemistry (hypoK or hyperCa)
- Acute abdominal series (if suspect obstruction)
- TSH
Treatment
- Stress adequate fluid (1.5L per day), fiber (10gm per day), and exercise
- Meds
- Fiber
- Bran: 1 cup daily
- Psyllium (Metamucil): 1 teaspoon TID
- Emollient
- Docusate (Colace): 100mg QD-BID (facilitates mixture of stool fat and water)
- Mineral oil (long term use causes malabsorption)
- Stimulants
- Saline laxative
- Milk of mangesia: 15-30 mL QD-BID
- Magnesium citrate: 100-240 mL QD-BID
- Hyperosmolar agents
- Lactulose 15-30 mL QD-BID
- Polyethylene glycol: 1 gallon/4h
- Miralax: 17gm
- Glycerin: 1 adult suppository PR, onset of action 15-30 min, then 1-2 doses per day
- Enemas
- Soap suds, saline, tap water enema (rectal distention, causing evacuation)[1]
- May add 50-100 mg of docusate liquid to saline or water enema
- Fleet Phospho-soda: 118 ml single enema dose, with maximum of x2 doses at least 1 hr apart
- Fiber
See Also
References
- ↑ Portalatin M and Winstead N. Medical Management of Constipation. Clin Colon Rectal Surg. 2012 Mar; 25(1): 12–19.
- ↑ Farah R. Fatal acute sodium phosphate enemas intoxication. Acta Gastroenterol Belg. 2005 Jul-Sep;68(3):392-3.
- ↑ Reedy JC, Zwiren GT. Enema-induced hypocalcemia and hyperphosphatemia leading to cardiac arrest during induction of anesthesia in an outpatient surgery center. Anesthesiology. 1983 Dec;59(6):578-9.
- ↑ Korzets A, Dicker D, Chaimoff C, Zevin D. Life-threatening hyperphosphatemia and hypocalcemic tetany following the use of fleet enemas. J Am Geriatr Soc. 1992 Jun;40(6):620-1.