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Emergency And Acute Medicine – Constipation
Description
Constipation is defined clinically using the Rome criteria, which require at least two of the following symptoms for a minimum of three months: straining during more than 25% of bowel movements, hard stools in more than 25% of bowel movements, a sensation of incomplete evacuation in more than 25% of bowel movements, or two or fewer bowel movements per week.
Pediatric Considerations
Defecation disorders account for approximately 3% of pediatric outpatient visits. Children with cerebral palsy are at increased risk of functional constipation. Pediatric constipation may be classified into anatomic causes, colonic neuromuscular disease such as Hirschsprung disease, and defecation disorders including functional constipation and nonretentive fecal soiling. Functional fecal retention is the most common cause and is often related to fear or pain with defecation, leading to irritability, abdominal cramping, decreased appetite, and early satiety.
Etiology
Metabolic and endocrine causes include diabetes, uremia, porphyria, hypothyroidism, hypercalcemia, pheochromocytoma, panhypopituitarism, and pregnancy. Functional and idiopathic causes include irritable bowel syndrome, diverticular disease, colonic inertia, megacolon or megarectum, pelvic intussusception, nonrelaxing puborectalis, rectocele, posthysterectomy syndrome, and descending perineum. Pharmacologic causes include analgesics, antacids, anticholinergics, anticonvulsants, antidepressants, antihypertensives, calcium channel blockers, diuretics, iron supplements, laxative abuse, monoamine oxidase inhibitors, opioids, paralytics, parasympatholytics, phenothiazines, and psychotropic medications. Neurologic causes include Parkinson disease, multiple sclerosis, cerebrovascular accidents, spinal cord injury, Hirschsprung disease, Chagas disease, neurofibromatosis, and autonomic neuropathy. Mechanical obstruction may result from neoplasm, stricture, hernia, or volvulus.
Clinical Features
Constipation represents a symptom rather than a primary diagnosis. Patients may report infrequent bowel movements, passage of hard stools, straining, abdominal distention or bloating, and difficulty with defecation. Liquid stool may pass around impacted feces, presenting as paradoxical diarrhea. Digital rectal examination may reveal firm stool or an empty rectal vault. History should include age at symptom onset, diet, exercise habits, stool characteristics, medication use, prior surgeries, use of laxatives or enemas, and symptoms suggestive of pelvic floor dysfunction. Physical examination may demonstrate abdominal masses from fecal loading and should include a focused rectal examination assessing sphincter tone, relaxation, stool consistency, and the presence of rectocele or cystocele.
Essential Evaluation
A detailed medical, surgical, and psychiatric history with careful physical examination is central to evaluation. The anorectal examination should assess for fissures, stenosis, neoplasm, sphincter tone abnormalities, perineal descent, tenderness, or spasm.
Diagnostic Tests And Interpretation
Laboratory testing is reserved for suspected metabolic or endocrine causes and may include a complete blood count, electrolytes, calcium, and thyroid function tests. Imaging is rarely required unless obstruction or other pathology is suspected. Abdominal radiographs may show fecal loading or colonic dilation. Computed tomography is indicated in elderly patients with abdominal pain or fever to exclude perforation. Contrast enemas may identify diverticulosis, megacolon, megarectum, Hirschsprung disease, or strictures.
Differential Diagnosis
The differential diagnosis includes bowel obstruction and secondary causes listed under etiology.
Initial Management
Intravenous access should be established in patients with significant abdominal pain or dehydration, and intravenous fluids administered as indicated.
Emergency Department Management
Initial treatment focuses on colonic evacuation using enemas, suppositories, or manual disimpaction when necessary. A long-term bowel regimen should be initiated, including increased noncaffeinated fluid intake, increased dietary fiber, regular exercise, stool softeners, and discontinuation or adjustment of constipating medications when possible.
Medications
Rectal therapies include sodium phosphate, mineral oil, and tap water enemas, as well as glycerin suppositories. Fiber supplements such as methylcellulose and psyllium may be used. Osmotic laxatives include lactulose, polyethylene glycol, and magnesium hydroxide. Stimulant laxatives include bisacodyl and senna. Stool softeners include docusate sodium and oral mineral oil.
Disposition And Follow-Up
Hospital admission is indicated for patients with severe abdominal pain, vomiting, bowel obstruction, peritonitis, or those unable to be adequately treated in the emergency department or home setting, particularly elderly or neurologically impaired patients. Patients may be discharged if pain free, adequately relieved of fecal burden, and without comorbid conditions requiring admission.
Follow-Up Recommendations
Primary care or gastroenterology follow-up is recommended for patients with chronic or recurrent constipation.
Practice Points And Common Errors
Patients should be counseled on dietary, fluid, and lifestyle modifications to reduce recurrence. A comprehensive history and physical examination are essential to avoid missing serious medical or surgical causes of constipation. Failure to consider secondary etiologies or medication-related causes is a common source of mismanagement.
Description
Constipation is defined clinically using the Rome criteria, which require at least two of the following symptoms for a minimum of three months: straining during more than 25% of bowel movements, hard stools in more than 25% of bowel movements, a sensation of incomplete evacuation in more than 25% of bowel movements, or two or fewer bowel movements per week.
Pediatric Considerations
Defecation disorders account for approximately 3% of pediatric outpatient visits. Children with cerebral palsy are at increased risk of functional constipation. Pediatric constipation may be classified into anatomic causes, colonic neuromuscular disease such as Hirschsprung disease, and defecation disorders including functional constipation and nonretentive fecal soiling. Functional fecal retention is the most common cause and is often related to fear or pain with defecation, leading to irritability, abdominal cramping, decreased appetite, and early satiety.
Etiology
Metabolic and endocrine causes include diabetes, uremia, porphyria, hypothyroidism, hypercalcemia, pheochromocytoma, panhypopituitarism, and pregnancy. Functional and idiopathic causes include irritable bowel syndrome, diverticular disease, colonic inertia, megacolon or megarectum, pelvic intussusception, nonrelaxing puborectalis, rectocele, posthysterectomy syndrome, and descending perineum. Pharmacologic causes include analgesics, antacids, anticholinergics, anticonvulsants, antidepressants, antihypertensives, calcium channel blockers, diuretics, iron supplements, laxative abuse, monoamine oxidase inhibitors, opioids, paralytics, parasympatholytics, phenothiazines, and psychotropic medications. Neurologic causes include Parkinson disease, multiple sclerosis, cerebrovascular accidents, spinal cord injury, Hirschsprung disease, Chagas disease, neurofibromatosis, and autonomic neuropathy. Mechanical obstruction may result from neoplasm, stricture, hernia, or volvulus.
Clinical Features
Constipation represents a symptom rather than a primary diagnosis. Patients may report infrequent bowel movements, passage of hard stools, straining, abdominal distention or bloating, and difficulty with defecation. Liquid stool may pass around impacted feces, presenting as paradoxical diarrhea. Digital rectal examination may reveal firm stool or an empty rectal vault. History should include age at symptom onset, diet, exercise habits, stool characteristics, medication use, prior surgeries, use of laxatives or enemas, and symptoms suggestive of pelvic floor dysfunction. Physical examination may demonstrate abdominal masses from fecal loading and should include a focused rectal examination assessing sphincter tone, relaxation, stool consistency, and the presence of rectocele or cystocele.
Essential Evaluation
A detailed medical, surgical, and psychiatric history with careful physical examination is central to evaluation. The anorectal examination should assess for fissures, stenosis, neoplasm, sphincter tone abnormalities, perineal descent, tenderness, or spasm.
Diagnostic Tests And Interpretation
Laboratory testing is reserved for suspected metabolic or endocrine causes and may include a complete blood count, electrolytes, calcium, and thyroid function tests. Imaging is rarely required unless obstruction or other pathology is suspected. Abdominal radiographs may show fecal loading or colonic dilation. Computed tomography is indicated in elderly patients with abdominal pain or fever to exclude perforation. Contrast enemas may identify diverticulosis, megacolon, megarectum, Hirschsprung disease, or strictures.
Differential Diagnosis
The differential diagnosis includes bowel obstruction and secondary causes listed under etiology.
Initial Management
Intravenous access should be established in patients with significant abdominal pain or dehydration, and intravenous fluids administered as indicated.
Emergency Department Management
Initial treatment focuses on colonic evacuation using enemas, suppositories, or manual disimpaction when necessary. A long-term bowel regimen should be initiated, including increased noncaffeinated fluid intake, increased dietary fiber, regular exercise, stool softeners, and discontinuation or adjustment of constipating medications when possible.
Medications
Rectal therapies include sodium phosphate, mineral oil, and tap water enemas, as well as glycerin suppositories. Fiber supplements such as methylcellulose and psyllium may be used. Osmotic laxatives include lactulose, polyethylene glycol, and magnesium hydroxide. Stimulant laxatives include bisacodyl and senna. Stool softeners include docusate sodium and oral mineral oil.
Disposition And Follow-Up
Hospital admission is indicated for patients with severe abdominal pain, vomiting, bowel obstruction, peritonitis, or those unable to be adequately treated in the emergency department or home setting, particularly elderly or neurologically impaired patients. Patients may be discharged if pain free, adequately relieved of fecal burden, and without comorbid conditions requiring admission.
Follow-Up Recommendations
Primary care or gastroenterology follow-up is recommended for patients with chronic or recurrent constipation.
Practice Points And Common Errors
Patients should be counseled on dietary, fluid, and lifestyle modifications to reduce recurrence. A comprehensive history and physical examination are essential to avoid missing serious medical or surgical causes of constipation. Failure to consider secondary etiologies or medication-related causes is a common source of mismanagement.
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