CONSTIPATION Flashcards
Pertinent Anatomy
(1) Large intestine
(a) Cecum
(b) Rectosigmoid colon
(2) Rectum
(3) Anus
It consists of sensory and motor functionsIt consists of sensory and motor functions
When sensory inputs are received, defecation
consists of a coordinated colonic peristalsis, rectal contraction and early anal relaxation.
most common digestive complaint in the United States.
Constipation
Constipation is defined based on
Rome IV criteria often used for diagnosis of
constipation.
(a) as infrequent stools (fewer than three in a week) OR
(b) hard stools, excessive straining, lumpy hard stools, sensation of incomplete
evacuation, or sensation of anorectal obstruction or blockage.
Constipation may originate primarily from within the
colon and rectum or may originate
externally.
Multifactorial Causes of constipation
(a) Diminishing intake of fiber associated with decreased fluid intake (most common)
(b) Systemic diseases (hypothyroidism, hyperparathyroidism, diabetes, chronic
neurologic disorders)
(c) Medications (calcium-channel blockers, iron, narcotic analgesics, and antipsychotics)
(d) Structural abnormalities (Colonic mass with obstruction; neoplasm
(Adenocarcinoma), Anal fissure)
(e) Slow colonic transit, particularly in patients with a history of chronic laxative abuse.
Slow colonic transit may be psychogenic or idiopathic.
(f) Irritable bowel syndrome — Irritable bowel syndrome with predominant constipation
(IBS-C) is characterized by abdominal pain with altered bowel habits. Many have
visceral hypersensitivity.
(g) Hirschsprung disease
A thorough history must be obtained. Patients may complain of
(a) Infrequent stool
(b) Excessive straining
(c) Sense of incomplete evacuation
(d) Need for digital manipulation
Differential Diagnosis
(1) Fecal impaction (Patients with fecal impaction must be disimpacted manually)
(2) Intestinal pseudo-obstruction (Ogilvie Syndrome)
(3) Intestinal Obstruction- refer to surgery
Lab
(1) Complete blood count for anemia.
(2) Thyroid function tests for suspected hypothyroidism.
(3) Electrolyte abnormalities (specifically hypokalemia and hypercalcemia).
RAD
(1) Upright chest film and abdominal flat and erect films for the presence or absence of
intestinal obstruction.
(2) Abdominal films to assess stool burden
Treatment
(1) Adverse psychosocial issues should be identified and addressed
(2) First line of treatment includes
(a) Strict dietary changes and an exercise regimen.
(b) Increased water intake AND
(c) Fiber supplementation (Metamucil, Benefiber, psyllium products (as prescribed on
bottle)).
1) There is usually no immediate response to fiber therapy. Therefore,
increase doses gradually over 7-10 days.
Second line of treatment includes
(a) Emollients
1) Docusate sodium (Colace) - Stool softener
2) Dose: 100 mg daily to twice daily
(b) Stimulants
1) Bisacodyl (Dulcolax) - Stimulant Laxative
a) Dose: 5-15 mg PO daily or 10 mg PR TID
(c) Saline laxative
1) Magnesium hydroxide (Milk of Magnesia) - Osmotic laxative
a) Dose: 15-30 mL daily to twice daily (withheld from patients with impaired
renal function)
2) Magnesium citrate - Osmotic laxative
a) Dose: 100-300 mL PO divided qd-bid
(d) Hyperosmolar agents
1) Sorbitol - hyperosmolar laxative
a) Dose: 15-30 mL PO qd-bid
2) Polyethylene glycol (MiraLAX)
a) Dose: 1 capful PO qd-bid, mix with at least 8 oz of fluid and drink all at once
Third line of treatment includes
(a) Suppository - Glycerin suppository PR qd
(b) Enemas - Fleets enema
Uncomplicated cases disposition
Retain onboard
