Constipation
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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
Clinical Features
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
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Non-GI Look-a-Likes
Evaluation
- Rectal exam
- Guaiac
- Chemistry (hypokalemia or hypercalcemia)
- CT abdomen/pelvis (if suspect obstruction)
- TSH
Treatment
- 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
- 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
- No more than 2 doses in a 24 hr period may be administered without serum phos, mag, calcium levels[2]
- May observe hyperphosphatemia, hypocalcemia, hypomagnesemia
- High risk patients: renal impairement, abnormal gut motility, IBD, elderly, cardiac co-morbidities[3][4]
Disposition
- Normally outpatient
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.