Constipation

Background

  • Acute constipation is intestinal obstruction until proven otherwise
  • Red flags:

Differential Diagnosis

Acute

  1. Bowel obstruction
    1. Tumor, stricture, hernia, adhesion, volvulus, fecal impaction
  2. New medicine
    1. Opiods, antipsychotic, anticholinergics, antacid, antihistamines
  3. Change in exercise
  4. Change in diet
  5. Pain rectal conditions (e.g. anal fissure, hemorrhoids)

Chronic

  1. Acute causes
  2. Hypothyroidism
  3. Electrolytes
    1. Hypomagnesia
    2. Hypercalcemia
  4. Hypokalemia

Work-Up

  1. Rectal exam
  2. Guaiac
  3. Chemistry (hypoK or hyperCa)
  4. Acute abdominal series (if suspect obstruction)
  5. TSH

Treatment

  1. Stress adequate fluid (1.5L per day), fiber (10gm per day), and exercise
  2. 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)
      2. Mineral oil (long term use causes malabsorption)
    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
      4. Glycerin: 1 adult suppository PR, onset of action 15-30 min, then 1-2 doses per day
    6. Enemas
      1. Soap suds, saline, tap water enema (rectal distention, causing evacuation)[1]
      2. May add 50-100 mg of docusate liquid to saline or water enema
      3. Fleet Phospho-soda: 118 ml single enema dose, with maximum of x2 doses at least 1 hr apart
        1. No more than 2 doses in a 24 hr period may be administered without serum phos, mag, calcium levels[2]
        2. May observe hyperphosphatemia, hypocalcemia, hypomagnesemia
        3. High risk pts: renal impairement, abnl gut motility, IBD, elderly, cardiac co-morbidities[3][4]

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.
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