Constipation: Difference between revisions

Revision as of 05:45, 30 July 2011

Background

Acute constipation is intestinal obstruction until proven otherwise
Red flags:
- Weight loss
- Rectal bleeding/melena
- N/V
- Fever
- Rectal pain
- Change in stool caliber

DDX

Acute

Obstruction
1. Tumor, stricture, hernia, adhesion, volvulus, fecal impaction
New medicine
1. Opiods, antipsychotic, anticholinergic, antacid, antihistamine
Change in exercise
Change in diet
Pain rectal conditions (e.g. anal fissure, hemorrhoids)

Chronic

Acute causes
Hypothyroidism
Electrolytes
1. Hypomagnesia
2. Hypercalcemia
Hypokalemia

Work-Up

Rectal exam
Guaiac
Chemistry (hypoK or hyperCa)
Acute abd series (if suspect obstruction)
TSH

Treatment

Stress adequate fluid (1.5L per day), fiber (10gm per day), and exercise
Meds
1. Fiber
  1. Bran: 1 cup daily
  2. Psyllium (metamucil): 1 teaspoon TID
2. Emollient
  1. Docusate (colace): 100mg QD-BID (facilitates mixture of stool fat and water)
3. Stimulants
  1. Bisacodyl (dulcolax): 10mg PR TID
  2. Senna: Two tab PO QD-BID
4. Saline laxative
  1. Milk of mangesia: 15-30 mL QD-BID
  2. Magnesium citrate: 100-240 mL QD-BID
5. Hyperosmolar agents
  1. Lactulose 15-30 mL QD-BID
  2. Polyethylene glycol: 1 gallon/4h
  3. Miralax: 17gm

Source

Tintinalli

Authors:

@@ Line 1: / Line 1: @@
-==Workup==
+==Background==
+*Acute constipation is intestinal obstruction until proven otherwise
+*Red flags:
+**Weight loss
+**Rectal bleeding/melena
+**N/V
+**Fever
+**Rectal pain
+**Change in stool caliber
+==DDX==
 ===Acute===
-#CBC (anemia)
+#Obstruction
-#Chem7 (hypoK or hyperCa)
+##Tumor, stricture, hernia, adhesion, volvulus, fecal impaction
-#TSH
+#New medicine
+##Opiods, antipsychotic, anticholinergic, antacid, antihistamine
+#Change in exercise
+#Change in diet
+#Pain rectal conditions (e.g. anal fissure, hemorrhoids)
 ===Chronic===
-#outpt
+#Acute causes
+#Hypothyroidism
+#Electrolytes
+##Hypomagnesia
+##Hypercalcemia
+#Hypokalemia
-==Differential==
+==Work-Up==
-#Acute
+#Rectal exam
-##Diet
+#Guaiac
-###Dec fluids
+#Chemistry (hypoK or hyperCa)
-###Dec fiber
+#Acute abd series (if suspect obstruction)
-##Drugs
+#TSH
-###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==
-===Basic===
+#Stress adequate fluid (1.5L per day), fiber (10gm per day), and exercise
-Do not use colace
+#Meds
+##Fiber
-#Fiber (bran not rughage)
+###Bran: 1 cup daily
-#Increased fluids
+###Psyllium (metamucil): 1 teaspoon TID
-#Bulk agents (Metamucil)
+##Emollient
-#Exercise
+###Docusate (colace): 100mg QD-BID (facilitates mixture of stool fat and water)
-#Respond quickly urge to defecate
+##Stimulants
+###Bisacodyl (dulcolax): 10mg PR TID
-===Acute===
+###Senna: Two tab PO QD-BID
-#Mineral oil (peds)
+##Saline laxative
-##15-30mL per yr of age (QD-BIDx3dy)
+###Milk of mangesia: 15-30 mL QD-BID
-#Milk of Mag
+###Magnesium citrate: 100-240 mL QD-BID
-##15-30mL (QD-BID)
+##Hyperosmolar agents
-##cotraindicated with renal failure
+###Lactulose 15-30 mL QD-BID
-#Mag Citrate
+###Polyethylene glycol: 1 gallon/4h
-##200mL once
+###Miralax: 17gm
-##cotraindicated with renal failure
-#Fleets Enema
-===Algorithm===
-#Associate pain?
-##Pain --> hemorrhoids?
-###Yes --> hydrocort, etc
-###No --> fissure?
-####Yes --> (treat, ?IBD)
-####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 ==
-/12/06 DONALDSON (adapted from Rosen)
+Tintinalli
 [[Category:GI]]