Constipation

Workup

Chronic --> outpt

Acute --> CBC (anemia), Chem7 (hypoK or hyperCa), TSH

Differential

I. Acute

    A. Diet

         1) Dec fluids

         2) Dec fiber

    B. Drugs

         1) Anticholinergics

         2) Antacids

         3) Antihypertensives

         4) Narcotics

         5) Symptathomimetics

         6) Laxative abuse

         7) NSAIDS

    C. Daily routine

         1) Immobility/lack exercis

         2) Travel

         3) Stress

         4) Failure respond to urge

    D. Disease

         1) Anatomic

              i. Painful (hemorrhoids, fissure)

              ii. Intrinsic (diverticulitis, CA, obstruction)

         2) Metabolic

              i. Hypothyrd/adrenal

              ii. Hypokal/Ca/RF

II. Chronic

    A. Hypertonic

         1) IBD

         2) Diverticulosis

    B. Hypotonic

         1) Neurogenic

              i. Dementia/CVA

              ii. DM

              iii. MS/ALS

              iv. Spinal cord lesion

              v. Parkinson's

         2) Psychogenic (psychosis)

         3) Debilitated

    C. Habit (toilet training)

Treatment

Basic

• do not use colace

1) Fiber (bran not rughage)

2) Increased fluids

3) Bulk agents (Metamucil)

4) Exercise

5) Respond quickly urge to defecate

Acute:

1) Mineral oil (peds)

--> 15-30mL per yr of age (QD-BIDx3dy)

2) Milk of Mag

--> 15-30mL (QD-BID)

-cotraindicated with renal failure

3) Mag Citrate

--> 200mL once

-cotraindicated with renal failure

4) Fleets Enema

Algorithm

I. Associate pain?

    A. Pain --> hemorrhoids?

         1) Yes --> hydrocort, etc

         2) No --> fissure?

              i) Yes --> (treat, ?IBD)

              ii) No --> (GI ref, ?mass lesion)

    B. No pain --> urge to defecate?

         1) Yes --> stool in vault?

              i) Yes --> neuro, chronic dz

              ii) No --> R/O meds, electrolyes, DM, thyroid --> IBS

    2) No --> dementia, retardation, DM, myopathy, obstruction

Source

3/12/06 DONALDSON (adapted from Rosen)