Constipation, Emergency Medicine

Basics

Description

Rome Criteria for the diagnosis of constipation requires 2 or more of the following for at least 3 mo: �

Straining >25% of the time
Hard stools >25% of the time
Incomplete evacuation >25% of the time
2 or fewer bowel movements per wk

3% of pediatric outpatient visits are because of defecation disorders.
Children with cerebral palsy often develop functional constipation.
Can be classified into subgroups:
- Constipation with anatomical origins (anal stenosis/strictures, ectopic anus, imperforate anus, sacrococcygeal teratomas)
- Colonic neuromuscular disease (Hirschsprung disease)
- Defecation disorders (functional constipation and nonretentive fecal soiling)
- Function fecal retention
Most common cause of fecal retention and soiling in children is functional fecal retention:
- Caused by fears associated with defecation
- Associated with irritability, abdominal cramps, decreased appetite, early satiety

Etiology

Metabolic and endocrine:
- Diabetes
- Uremia
- Porphyria
- Hypothyroidism
- Hypercalcemia
- Pheochromocytoma
- Panhypopituitarism
- Pregnancy
Functional and idiopathic:
- Colonic irritable bowel syndrome
- Diverticular disease
- Colonic inertia
- Megacolon/megarectum
- Pelvic intussusception
- Nonrelaxing puborectalis
- Rectocele/sigmoidocele
- Posthysterectomy syndrome
- Descending perineum
Pharmacologic:
- Analgesics
- Anesthetics
- Antacids
- Anticholinergics
- Anticonvulsants
- Antidepressants
- Antihypertensives
- Calcium channel blockers
- Diuretics
- Ferrous compounds
- Laxative abuse
- MAOIs
- Opiates
- Paralytic agents
- Parasympatholytics
- Phenothiazines
- Psychotropics
Neurologic:
- Central Parkinson disease
- Multiple sclerosis
- Cerebrovascular accidents
- Spinal cord lesions/injury
- Peripheral Hirschsprung disease
- Chagas disease
- Neurofibromatosis
- Autonomic neuropathy
Mechanical obstruction:
- Neoplasm
- Stricture
- Hernia
- Volvulus

Diagnosis

Signs and Symptoms

Constipation is a symptom, not a disease.
Passage of hard stool
Straining/difficulty passing stool
Infrequent bowel movements
Abdominal distention/bloating
Firm/hard stool on digital rectal exam:
- May have empty rectal vault
Diarrhea (liquid stool passes around firm feces)

History

Age of onset of symptoms
Diet and exercise regimen
Stool size, caliber, consistency, frequency, ease of defecation
Medical and surgical history:
- Medications that can slow colonic transit like β-blockers, high-dose calcium channel blockers, narcotics
Use of enemas, laxatives, and digital manipulation to facilitate defecation
Associated pelvic floor dysfunction:
- Urinary symptoms
- Rectocele

Physical Exam

Abdominal exam may reveal a mass due to stool
Rectal exam to assess for outlet obstruction:
- Ability to squeeze and relax the sphincter
- Is there a rectocele or cystocele?
- Assess firmness of stool

Essential Workup

Thorough history and physical exam: �

Medical, surgical, and psychiatric investigation and date of onset
Note abdominal distention, hernias, tenderness, or masses
Complete anorectal exam for anal stenosis, fissure, neoplasm, sphincter tone, perineal descent, tenderness, spasm

Diagnosis Tests & Interpretation

Lab

Only necessary when considering metabolic/endocrine disorders
CBC if inflammatory or neoplastic origin
Electrolytes and calcium indicated if at risk of:
- Hypokalemia
- Hypocalcemia
Thyroid function test if patient appears to be hypothyroid

Imaging

Rarely indicated unless an underlying process suspected
Abdominal radiograph:
- Large amount of feces in colon
- Dilated colon that needs decompression
CT scan of abdomen/pelvis to r/o perforation in elderly, constipated patient with abdominal pain/fever
Barium/Gastrografin enema study:
- Diverticulosis
- Megarectum
- Megacolon
- Hirschsprung disease
- Stricture from inflammation or tumor

Differential Diagnosis

See "Etiology."�
Bowel obstruction

Treatment

Pre-Hospital

Establish IV access for patients with significant abdominal pain. �

Initial Stabilization/Therapy

IV fluids for dehydrated/hypotensive patients �

Ed Treatment/Procedures

Clean out colon:
- Enemas, suppositories
- Manual disimpaction of hard stool
- Laxatives
Maintain bowel regimen:
- Increase noncaffeinated fluids (8-10 cups per day).
- Increase dietary fiber intake (20 g/day).
- Stool softeners
- Exercise
- Change medications causing constipation.

Medication

Enemas:
- Fleet: 120 mL (peds: 60-120 mL) per rectum (PR)
- Mineral oil: 60-150 mL (peds: 5-11 yr old, 30-60 mL; older than 12 yr, 60-150 mL) PR daily
- Tap water: 100-500 mL PR
Fiber supplements:
- Methylcellulose: 1 tbs in cup water PO daily to TID
- Psyllium: 1-2 tsp in cup of water/juice (peds: Younger than 6 yr, 1/4-1/2 tsp in 2 oz water or juice; 6-11 yr, 1/2-1 tsp in 4 oz water or juice; older than 12 yr, 1-2 tsp in cup water or juice) PO daily to TID
Laxatives (osmotic):
- Lactulose: 15-30 mL (peds: 1 mL/kg) PO daily to BID
- Polyethylene glycol: 17 g (peds: 0.8 g/kg/d dissolved in 4-8 oz of liquid) PO daily dissolved in liquid
- Milk of magnesia: 2400-4800 mg Mg hydroxide po (peds 6 mo-1 yr: 40 mg/kg Mg hydroxide; 2-5 yr: 400-1200 mg Mg hydroxide; 6-11 yr: 1200-2400 mg Mghydroxide; over 12 yrs: 2400-4800 mg Mg hydroxide) QD or divided bid-qid prn
Laxatives (stimulant):
- Bisacodyl: 10-15 mg PO daily (peds: Younger than 3 yr, 5 mg PR daily; 3-12 yr, 5-10 mg PO/PR daily; older than 12 yr, 5-15 mg PO daily or 10 mg PR daily)
- Senna: 2 tabs PO daily to BID (peds: 2-6 yr, 1/2-1 tab PO daily to BID; 6-12 yr, 1-2 tabs PO daily to BID; older than 12 yr, 2-4 tabs PO daily to BID)
Stool softeners:
- Docusate sodium: 100 mg (peds: 3-5 mg/kg/d in div. doses) PO daily to BID
- Mineral oil: 15-45 mL (peds: 5-15 mL) PO daily
Suppositories:
- Glycerin: 1 adult (peds: Infant, 1 infant suppository) PR PRN

Follow-Up

Disposition

Admission Criteria

Patients with severe abdominal pain, nausea, and emesis
Neurologically impaired, elderly, morbidly obese who cannot be cleaned out in the ED or home
Bowel obstruction/peritonitis

Discharge Criteria

No co-morbid illness requiring admission
Pain free
Adequately cleaned out

Issues for Referral
GI follow-up for further evaluation and treatment �

Followup Recommendations

Primary care or GI follow-up for patients with longstanding constipation �

Pearls and Pitfalls

Advise patients regarding appropriate dietary and lifestyle changes to decrease incidence of constipation.
Perform thorough history and physical exam to exclude significant medical or surgical etiologies for constipation.

Additional Reading

Doody �DP, Flores �A, Rodriguez �LA. Evaluation and management of intractable constipation in children. Semin Colon Rectal Surg. 2006;17(1):29-37.
Ford �AC, Talley �NJ. Laxatives for chronic constipation in adults. BMJ. 2012;345:e6168.
Leung �L, Riutta �T, Kotecha �J, et al. Chronic constipation: An evidence-based review. J Amer Board of Fam Med. 2011;24(4):436-451.
Talley �N. Differentiating functional constipation from constipation-predominant irritable bowel syndrome: Management implications. Rev Gastroenterol Disord. 2005;5(1):1-9.
Wexner �SD, Pemberton �JH, Beck �DE, et al., eds. The ASCRS Textbook of Colon and Rectal Surgery. Springer; 2007.

Codes

ICD9

564.00 Constipation, unspecified
564.09 Other constipation
564.8 Other specified functional disorders of intestine
564.01 Slow transit constipation
751.3 Hirschsprungs disease and other congenital functional disorders of colon

ICD10

K59.00 Constipation, unspecified
K59.09 Other constipation
K59.8 Other specified functional intestinal disorders
K59.01 Slow transit constipation
Q43.1 Hirschsprungs disease

SNOMED

14760008 Constipation (disorder)
197118003 Constipation - functional (disorder)
35298007 Slow transit constipation
204739008 Hirschsprungs disease (disorder)
249517009 Constipation alternates with diarrhea (disorder)

Home

Erectile Dysfunction

Doctor123.org