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

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

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

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.

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 (Innovative Sport Medicine Calgary). His interests are in paediatrics, 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…..