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Constipation, Emergency Medicine

Basics

Description

- Mechanical obstruction: - Neoplasm - Stricture - Hernia - Volvulus

- 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

- 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

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

  • 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 defecationAssociated with irritability, abdominal cramps, decreased appetite, early satiety

Etiology

  • Metabolic and endocrine:DiabetesUremiaPorphyriaHypothyroidismHypercalcemiaPheochromocytomaPanhypopituitarismPregnancy
  • Functional and idiopathic:Colonic irritable bowel syndromeDiverticular diseaseColonic inertiaMegacolon/megarectumPelvic intussusceptionNonrelaxing puborectalisRectocele/sigmoidocelePosthysterectomy syndromeDescending perineum
  • Pharmacologic:AnalgesicsAnestheticsAntacidsAnticholinergicsAnticonvulsantsAntidepressantsAntihypertensivesCalcium channel blockersDiureticsFerrous compoundsLaxative abuseMAOIsOpiatesParalytic agentsParasympatholyticsPhenothiazinesPsychotropics
  • Neurologic:Central Parkinson diseaseMultiple sclerosisCerebrovascular accidentsSpinal cord lesions/injuryPeripheral Hirschsprung diseaseChagas diseaseNeurofibromatosisAutonomic neuropathy
  • Mechanical obstruction:NeoplasmStrictureHerniaVolvulus

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 symptomsRectocele

Physical Exam

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

Essential Workup

Thorough history and physical exam: пїЅ

  • 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:
  • Thyroid function test if patient appears to be hypothyroid

Imaging

  • Rarely indicated unless an underlying process suspected
  • Abdominal radiograph:Large amount of feces in colonDilated 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:DiverticulosisMegarectumMegacolonHirschsprung diseaseStricture from inflammation or tumor

Differential Diagnosis

  • See "Etiology."пїЅ
  • Bowel obstruction

Treatment

Pre-Hospital

Establish IV access for patients with significant abdominal pain. пїЅ

Initial Stabilization/Therapy

IV fluids for dehydrated/hypotensive patients пїЅ

Ed Treatment/Procedures

  • Clean out colon:Enemas, suppositoriesManual disimpaction of hard stoolLaxatives
  • Maintain bowel regimen:Increase noncaffeinated fluids (8-10 cups per day).Increase dietary fiber intake (20 g/day).Stool softenersExerciseChange 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 dailyTap water: 100-500 mL PR
  • Fiber supplements:Methylcellulose: 1 tbs in cup water PO daily to TIDPsyllium: 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 BIDPolyethylene glycol: 17 g (peds: 0.8 g/kg/d dissolved in 4-8 oz of liquid) PO daily dissolved in liquidMilk 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 BIDMineral 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 пїЅ

Followup Recommendations

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

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 пїЅDP, Flores пїЅA, Rodriguez пїЅLA. Evaluation and management of intractable constipation in children. Semin Colon Rectal Surg. 2006;17(1):29-37.
  • Ford пїЅAC, Talley пїЅNJ. Laxatives for chronic constipation in adults. BMJ. 2012;345:e6168.
  • Leung пїЅL, Riutta пїЅT, Kotecha пїЅJ, et al. Chronic constipation: An evidence-based review. J Amer Board of Fam Med. 2011;24(4):436-451.
  • Talley пїЅN. Differentiating functional constipation from constipation-predominant irritable bowel syndrome: Management implications. Rev Gastroenterol Disord. 2005;5(1):1-9.
  • Wexner пїЅSD, Pemberton пїЅJH, Beck пїЅDE, et al., eds. The ASCRS Textbook of Colon and Rectal Surgery. Springer; 2007.

See Also (Topic, Algorithm, Electronic Media Element)

  • Abdominal Pain
  • Bowel Obstruction

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)