Constipation

CRACKCast E032 – Constipation

In CRACKCast, Podcast by Adam Thomas1 Comment

This episode of CRACKCast cover’s Rosen’s Chapter 32, Constipation1. Constipation is a common presenting symptoms in the ER in our geriatric population, and a good approach can help prevent unnecessary testing.

Shownotes – PDF Link

Rosen’s in Perspective

  • Constipation as lots of different definitions:
    • straining
    • hard/infrequent stools
    • pain during BMs,
      *Always have the patient define what they mean by constipation*
  • Chronic constipation > 3 months
  • Constipation + inability to pass flatus = obstipation
  • Constipation is most common in
    • Women
    • Elderly
    • low SES
    • high BMIs
    • low fiber
    • sedentaryism
    • multiple medication
  • GI tract normally sees 10 L of fluids and secretions. The small intestine absorbs all but 500 ml
  • The colon uses these residues from the ileum to ferment and salvage nutrients and water.
  • Stool evacuation and transport depends on:
    • Neurotransmitters
    • Colonic reflexes

Diagnostic approach:

  •  PRIMARY causes
    • Congenital
      • Hirschprung’s disease
      • imperforate anus
      • Anorectal atresia / aganglionosis
      • IBS
  • SECONDARY causes
    •  Neurologic
      • MS, Parkinson’s
      • Spinal cord injury
    •  Metabolic
      • Diabetes,
      • Hypercalcemia / hypokalemia / hypoMag
      • Hypothyroidism
    •  Myopathies
      • Systemic sclerosis / amyloidosis
    •  Structural
      • Tumour or stricture
      • Intussusception
      • Rectocele / rectal prolapse
    • Medication related
      • Opiates
      • Iron / calcium
      • Antidepressants
      • Diuretics
      • Antipsychotics
      • Anticholinergics
      • Antiepileptics
      • Antiparkinson agents
    •  Psych
      • Abuse, eating disorders, affective disorders
    •  Other:
      • Dehydration / immobility / dietary factors
      • Pregnancy / post-operative pain

Diagnostic algorithm

  • Pivotal findings:
    • History
      • ..usually tells you the dx
      • Alarm symptoms:
        • Fever, anorexia, vomiting, blood in stool, wt loss,
        • Onset in age > 50 yrs
      • Thorough review of medications! And OTC agents
    • Physical examination
      • Key to do:
        • Abdominal exam
        • Rectal exam
          • Fissures, hemorrhoids, rectal prolapse,
          • DRE for masses, proctitis, gross blood
    • Ancillary testing
      • Usually need advanced imaging if abdominal pain is significant – xray not useful
      • Very little blood work actually needed
      • Should screen for colon CA in anyone > 50 yrs.

Constipation should be a diagnosis of EXCLUSION in patients with abdominal pain

 

Empirical management:

  • See box 32-2 and table 32-1
  • Treat underlying contributing factors as needed:
    • Anorectal fissures, abscesses
    • Withholding medications!
  • Core program for everyone!
    • Fiber
    • Fluids
    • Exercise
  • Treatment agents:
    1. bulking agents – fiber that is indigestible
      • Psyllium (metamucil) – up to 20 g daily WITH plenty liquids
      • Prunes,
      • figs
    2. osmotic salts
      • Sodium phosphate – 30 ml prn.
      • citrate – milk of magnesia – 30-45 ml daily
    3. sugars
      • Lactulose –
      • PEG 3350 – 17 g BID
        • Golytely or miralax
    4. stool softeners
      • Mineral oil – 5 – 15 ml qhs
      • Colace 100 mg BID – of little use
    5. stimulant laxatives
      • Senokot 8 – 34 mg daily
    6. suppositories and enemas
      • For poop in the rectum
        • Glycerin suppositories
  • Warm tap water enemas for large amounts of stool in the rectum
  • Fecal disimpaction for severe constipation

Disposition

  • People with medically necessary medications causing constipation NEED to be on a regular regimen
  • Some people need special medications for chronic constipation
    • Relistor or Amitiza
  • In palliative patients use of:
    • Methlynatrexone for blocking the opioid receptors in the gut

 

This post was copyedited and uploaded by Michael Bravo (@bravbro).

1.
Marx J. Rosen’s Emergency Medicine – Concepts and Clinical Practice. Mosby; 2015.
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Adam Thomas

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Adam Thomas
- 2 days ago
Chris Lipp
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine. His interests are in endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..