Constipation: Difference between revisions

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==Workup==
''This page is for '''adult''' patients; for pediatric patients see [[constipation (peds)]].''
===Acute===
==Background==
#CBC (anemia)
[[File:Diameters of the large intestine.png|thumb|Normal inner diameters of colon sections.]]
#Chem7 (hypoK or hyperCa)
[[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]]
#TSH
*Acute constipation is intestinal obstruction until proven otherwise


===Chronic===
===Red flags===
#outpt
*Weight loss
*[[Rectal bleeding]]/melena
*[[Nausea/vomiting]]
*[[Fever]]
*Rectal pain
*Change in stool caliber


==Differential==
==Clinical Features==
#Acute
[[File:BristolStoolChart.png|thumb|Bristol Stool Chart.]]
##Diet
*Decreased frequency of bowel movements
###Dec fluids
*Hard, dry, and/or difficult to pass stool
###Dec fiber
##Drugs
###Anticholinergics
###Antacids
###Antihypertensives
###Narcotics
###Symptathomimetics
###Laxative abuse
###NSAIDS
##Daily routine
###Immobility/lack exercis
###Travel
###Stress
###Failure respond to urge
##Disease
###Anatomic
####Painful (hemorrhoids, fissure)
####Intrinsic (diverticulitis, CA, obstruction)
###Metabolic
####Hypothyrd/adrenal
####Hypokal/Ca/RF
#Chronic
##Hypertonic
###IBD
###Diverticulosis
##Hypotonic
###Neurogenic
####Dementia/CVA
####DM
####MS/ALS
####Spinal cord lesion
####Parkinson's
###Psychogenic (psychosis)
###Debilitated
##Habit (toilet training)


==Treatment==
==Differential Diagnosis==
===Basic===
{{Constipation DDX}}
Do not use colace
{{Anorectal DDX}}
{{DDX abdominal distention}}


#Fiber (bran not rughage)
==Evaluation==
#Increased fluids
===Work up===
#Bulk agents (Metamucil)
*Digital rectal exam
#Exercise
*Abdominal panel
#Respond quickly urge to defecate
**CBC
**Chemistry ([[hypokalemia]] or [[hypercalcemia]])  
**LFTs + lipase
**Consider coagulation studies (PT, PTT, INR), as a marker of liver function
*Consider [[TSH]] if concern for [[hypothyroid]] related [[constipation]]
*Consider [[lactate]] if concern for [[stercoral colitis]]
*CT if abdominal tenderness, elderly, or severe presentation
**'''Constipation should not cause abdominal tenderness on exam'''
**CT may show stool burden in colon/rectum


===Acute===
===Diagnosis===
#Mineral oil (peds)
*Diagnosis is frequently clinical
##15-30mL per yr of age (QD-BIDx3dy)
*In patients with concerning symptoms/risk factors, CT can confirm diagnosis and rule out more emergent conditions
#Milk of Mag
##15-30mL (QD-BID)
##cotraindicated with renal failure
#Mag Citrate
##200mL once
##cotraindicated with renal failure
#Fleets Enema


===Algorithm===
==Management==
#Associate pain?
*Adequate fluid (1.5L per day)
##Pain --> hemorrhoids?
*Fiber (10gm per day)
###Yes --> hydrocort, etc
**Bran: 1 cup daily
###No --> fissure?
**[[Psyllium]] (Metamucil): 1-2 teaspoon TID
####Yes --> (treat, ?IBD)
*Exercise
####No --> (GI ref, ?mass lesion)
##No pain --> urge to defecate?
###Yes --> stool in vault?
####Yes --> neuro, chronic dz
####No --> R/O meds, electrolyes, DM, thyroid --> IBS
###No --> dementia, retardation, DM, myopathy, obstruction


==Source ==
===Medication options===
3/12/06 DONALDSON (adapted from Rosen)
*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 3350|PEG]]: 1 gallon/4h
**[[Polyethylene glycol 3350|PEG]](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 patients: renal impairement, abnormal 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>
====Gastrografin PO====
*Gastrografin through NG or OG decreases bowel wall edema and increases bowel motility<ref>Assalia A, Schein M, Kopelman D, et al. Therapeutic effect of oral Gastrografin in adhesive, partial small-bowel obstruction: A prospective randomized trial. Surgery 1994; 115: 433-437.</ref>
**Diagnostic and therapeutic<ref>Chen SC, Lin FY, Lee PH, et al. Water-soluble contrast study predicts the need for early surgery in adhesive small bowel obstruction. Br J Surg 1998; 85: 1692-1694.</ref>
**100 cc of gastrografin through NG tube
**Transit may be observed through serial radiographs
***Contrast within the large bowel within 24 hrs suggest partial [[small bowel obstruction]]
***Contrast failing to reach large bowel within 24-48 hrs suggests complete obstruction, requiring laparotomy
**Therapeutic, may reduce necessary operative rate by ~75%<ref>Choi HK et al. Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial. Annals of Surgery. 2002;236(1).</ref>
*Avoid barium as it becomes inspissated in bowel, causing complete obstruction<ref>Choi HK et al. Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial. Annals of Surgery. 2002;236(1).</ref>
**If perforation occurs with barium, leakage can be lethal
**Gastrografin is water-soluble and relatively safer if perforation occurs
**Be aware that anaphylactoid reactions and serious aspirations have occurred rarely with Gastrografin, however<ref>Skucas J. Anaphylactoid reactions with gastrointestinal contrast media. AJR Am J Roentgenol 1997; 168: 962-964.</ref>
 
==Disposition==
*Normally outpatient
 
==See Also==
*[[Constipation (peds)]]
 
==References==
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]

Latest revision as of 15:50, 23 April 2025

This page is for adult patients; for pediatric patients see constipation (peds).

Background

Normal inner diameters of colon sections.
Anatomy of the anus and rectum.
  • Acute constipation is intestinal obstruction until proven otherwise

Red flags

Clinical Features

Bristol Stool Chart.
  • Decreased frequency of bowel movements
  • Hard, dry, and/or difficult to pass stool

Differential Diagnosis

Constipation

Anorectal Disorders

Non-GI Look-a-Likes

Abdominal distention

Evaluation

Work up

  • Digital rectal exam
  • Abdominal panel
    • CBC
    • Chemistry (hypokalemia or hypercalcemia)
    • LFTs + lipase
    • Consider coagulation studies (PT, PTT, INR), as a marker of liver function
  • Consider TSH if concern for hypothyroid related constipation
  • Consider lactate if concern for stercoral colitis
  • CT if abdominal tenderness, elderly, or severe presentation
    • Constipation should not cause abdominal tenderness on exam
    • CT may show stool burden in colon/rectum

Diagnosis

  • Diagnosis is frequently clinical
  • In patients with concerning symptoms/risk factors, CT can confirm diagnosis and rule out more emergent conditions

Management

  • Adequate fluid (1.5L per day)
  • Fiber (10gm per day)
    • Bran: 1 cup daily
    • Psyllium (Metamucil): 1-2 teaspoon TID
  • Exercise

Medication options

  • 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
    • PEG: 1 gallon/4h
    • PEG(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

Gastrografin PO

  • Gastrografin through NG or OG decreases bowel wall edema and increases bowel motility[5]
    • Diagnostic and therapeutic[6]
    • 100 cc of gastrografin through NG tube
    • Transit may be observed through serial radiographs
      • Contrast within the large bowel within 24 hrs suggest partial small bowel obstruction
      • Contrast failing to reach large bowel within 24-48 hrs suggests complete obstruction, requiring laparotomy
    • Therapeutic, may reduce necessary operative rate by ~75%[7]
  • Avoid barium as it becomes inspissated in bowel, causing complete obstruction[8]
    • If perforation occurs with barium, leakage can be lethal
    • Gastrografin is water-soluble and relatively safer if perforation occurs
    • Be aware that anaphylactoid reactions and serious aspirations have occurred rarely with Gastrografin, however[9]

Disposition

  • Normally outpatient

See Also

References

  1. ↑ Portalatin M and Winstead N. Medical Management of Constipation. Clin Colon Rectal Surg. 2012 Mar; 25(1): 12–19.
  2. ↑ Farah R. Fatal acute sodium phosphate enemas intoxication. Acta Gastroenterol Belg. 2005 Jul-Sep;68(3):392-3.
  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.
  4. ↑ 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.
  5. ↑ Assalia A, Schein M, Kopelman D, et al. Therapeutic effect of oral Gastrografin in adhesive, partial small-bowel obstruction: A prospective randomized trial. Surgery 1994; 115: 433-437.
  6. ↑ Chen SC, Lin FY, Lee PH, et al. Water-soluble contrast study predicts the need for early surgery in adhesive small bowel obstruction. Br J Surg 1998; 85: 1692-1694.
  7. ↑ Choi HK et al. Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial. Annals of Surgery. 2002;236(1).
  8. ↑ Choi HK et al. Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial. Annals of Surgery. 2002;236(1).
  9. ↑ Skucas J. Anaphylactoid reactions with gastrointestinal contrast media. AJR Am J Roentgenol 1997; 168: 962-964.
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