Project: Ghana Emergency Medicine Collaborative

Document Title: The Adult Patient With Constipation

Author(s): Joe Lex, MD, FACEP, FAAEM, (Temple University) 2013

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2

The Patient

with

Constipation

Joe Lex, MD, FAAEM

Temple University Hospital

Philadelphia, PA

Objectives

• Define constipation as determined

by the AGA

• Describe the physiology of normal

defecation

• List factors from the history which

provides clues to the seriousness

of its cause

Objectives

• Describe the 4 Ds and 3 Hs of

chronic constipation

• Explain potential severe

complications of constipation

• List the mechanism of action and

effectiveness for several

treatments for constipation

Some Definitions

Constipation: from Latin constipatio -

a crowding together

Obstipation: from Latin obstipatio - a

close pressure

Dyschezia: from Greek chezo - to

defecate

Aperient: from Latin aperiens - to

bring forth, produce

Some Definitions

Cathartic: from Greek - to cleanse

Purgative: from Latin purgativus -

remove by cleansing

Laxative: from Latin laxativus -

mitigating, assuaging

Physic: from Latin physica, physice -

to produce, grow

Some Definitions

Epsom Salts: sulphate of magnesia

having cathartic qualities;

originally prepared by boiling down

the mineral waters at Epsom,

England (home of racetrack)

Defecation in History

• Old Testament Jews could not

face or aim buttocks at Jerusalem

• Essenes could not dig on the

Sabbath, so did not defecate

• Muslims cannot face Mecca or turn

back on it, but cannot face sun or

moon

Defecation in History

• Ebers Papyrus: five intestinal

stimulants - figs, castor oil, seed

oil, aloes, and sweet beer

Defecation in History

• Hippocrates: “All diseases are

resolved either by the mouth, the

bowels, the bladder…”

John Harvey Kellogg, MD

From Battle Creek Michigan:

“One daily evacuation is chronic

constipation.”

“Who has not seen a prodigious

evacuation of the bowels at the

hands of a physician terminate a

case of insanity?”

Brother Will made breakfast foods...

“Intestinal Autointoxication”

Definition: self-poisoning from from

one’s own retained waste

(The constipated person) “…is

always working toward his own

destruction; he makes continual

attempts at suicide by

intoxication.”

- Charles Bouchard, 1906

“Intestinal Autointoxication”

Books published between 1900 and

1920 include...

The Conquest of Constipation

The Lazy Colon

Le Colon Homicide

Intestinal Management for Longer,

Happier Life

“Intestinal Autointoxication”

“…a burden, fermenting,

decomposing, putrefying, filling the

body with poisonous substances...

…sewer-like blood…

…the cause of ninety percent of

disease...

…constipation shortens life.”

“Intestinal Autointoxication”

Sir William Arbuthnot Lane of Guy’s

Hospital, London: performed

hundreds of colectomies to rid

patients of “…the cause of all the

hideous sequence of maladies

peculiar to civilization.”

Constipation Is a Symptom...

...not a diagnosis

• Usually need to identify cause to

effect proper treatment

• Definitive diagnosis often not

possible in ED

Constipation

Normal

Urgency

Diarrhea Kyle Thompson, Wikimedia Commons

Definition: Any Two of Four

• Straining to pass stool 25% of time

• Lumpy or hard stools 25% of time

• Incomplete sensation of

evacuation 25% of time

• Two or fewer stools per week

- American Gastroenterological Association

Frequent Self-Diagnosis

• Often self-diagnosed and treated

• >700 OTC laxatives

• Sales more than $1,000,000,000

per year in US

Frequent Self-Diagnosis

• Patients put premium on

“regularity”

• Concern when significant change

from normal pattern

Epidemiology

• 20% of population complains of at

least one episode constipation

• 98% are elderly

– 26% of elderly men affected

– 34% of elderly women affected

• 2,500,000 visits yearly to health

care providers

Epidemiology

• Laxatives used on regular basis by

– 30% of general population

– 60% of all elderly individuals,

– 75% of nursing home elderly

• Multifactorial: low dietary fiber,

sedentary habits, medicines,

neurologic diseases, decreased

thirst, etc.

Normal Physiology

• GI tract gets 9 to 10 liters per day

of secretions and ingested fluids

• Small intestine absorbs all but 500

to 600 ml

• Colon absorbs more

• About 100 ml/day of fluid lost in

the stool

Normal Physiology

• Water passively absorbed: follows

osmotic gradient produced by

sodium absorption

• Sodium actively absorbed: even

against large concentration

gradients

Normal Defecation

Rectum distends internal sphincter

relaxes external sphincter contracts

puborectalis muscle relaxes with

Valsalva pelvic floor ascends

anorectal angle straightens anal

canal opens straining

intraluminal pressure

Normal Defecation

• Constant pressure on rectum /

anal sphincter: 20 mmHg

• Normal defecation: 40 mmHg for 5

to 6 seconds

• Constipation and breath hold /

strain : 200 mmHg for 10 to 15

seconds (Valsalva)

Normal Defecation

• South American Indians, Africans:

diet of fruits, vegetables, grains

• Average American: meat, sugar,

white flour

• Stool bulk of former 3 to 5 times

that of latter

Abnormal Defecation

Motility imbalance between…

...churning nonpropulsive forces that

regulate constipation and fluid

absorption and

...propulsive forces that propel the

feces toward the rectum

• Normals: intestinal transit time and

bowel frequency age independent

Abnormal Defecation

Elderly patients with idiopathic

chronic constipation have...

...prolonged total gut transit times

(colonic inertia)

...decreased rectal sensitivity

...increased colonic absorption of

fluids from fecal material

...hard stools

Abnormal Defecation

• Ignoring urge to defecate due to

inconvenience, incapacity, or

painful anorectal lesions

• Resisting urge to defecate

suppresses normal sensory stimuli

evoked by rectal distention,

leading to chronic rectal distention

and decreased motor tone

Most Important Factor

• Diet, especially

adequate fluid

and fiber intake

Solarnu, Flickr

Jarlhelm, Wikimedia Commons

Pivotal Findings: History

• Thorough, detailed history:

usually identifies most likely

cause

• Define what patient means by

constipation

Pivotal Findings: History

• Character of stools: provide clue to

diagnosis, suggest seriousness

– Diarrhea alternating with

constipation: suggests obstructing

colonic mass lesion, irritable bowel

• Changes in diet and exercise

• New medications

Associated Symptoms

• Job, sleep habits, appetite, daily

activities, depression

• Flatulence and bloating: consider

malabsorption syndrome

Associated Symptoms

• Temperature elevation: invasive

infection, inflammatory disease,

prolonged fecal impaction

Associated Symptoms

Source Undetermined

Associated Symptoms

• Nausea and vomiting: nonspecific

– If present think acute obstruction

• Weakness: dehydration,

electrolyte imbalance

• Weight loss, decreased appetite:

debilitating diseases (e.g., cancer,

inflammatory bowel)

Associated Symptoms

• Abdominal pain

• Location and character may

localize specific disease process

• Not diagnostic of constipation

• May be dull, crampy, and visceral

Associated Symptoms

• Excessive gas

• Anorexia

• Fatigue

• Headache

• Low back pain

• Weakness

• Restlessness

Associated Symptoms

• Fecal impaction: may present with

low-grade fever, fecal

incontinence, alternating diarrhea

and constipation

• Most concerning symptoms: rectal

bleeding, change in stool caliber

– Suggest possible colorectal cancer

Four Ds of Constipation

• Diet

• Deficient fluid intake

• Deficient fiber intake

• Drugs

Drugs Causing Constipation

• Anticholinergics: antihistamines,

tricyclic anti-depressants,

phenothiazines, antiparkinsonian

agents, antispasmodics

• Antacids: AlOH, CaCO3

• Antihypertensives: diuretics,

CCBs, clonidine

Drugs Causing Constipation

• Narcotics / opioids

• Sympathomimetics: ephedrine,

terbutaline

• Laxative abuse

• NSAIDs

• Others: iron, phenytoin, barium,

bismuth, sucralfate, etc.

Herbals and “Alternatives”

• Variety of herbal laxatives at

health food stores

• Vegetable products containing

anthraquinones: aloe, senna,

cascara

• Work acutely: chronic efficacy and

safety less certain

– Melanosis coli: benign complication

Herbals and “Alternatives”

• High colonic: high-volume enemas

from alternative practitioners

• Some enemas contain unusual

salts: attempt to influence the

function of other organs

• Questionable hygiene: intestinal

parasite outbreaks reported

Physical Causes

• Immobility, lack of exercise

• Travel

• Psychosocial stress, depression,

psychosis

• Failure to respond to the urge to

defecate

Diseases - Anatomic

• Painful perianal lesion: fissures,

hemorrhoids, abscesses, herpes

• Intrinsic bowel lesions: carcinoma,

diverticulitis, obstruction

Diseases - Metabolic

• Diabetes mellitus

• Hypercalcemia

• Hypokalemia

• Porphyria

Diseases - Endocrine

• Hypothyroidism

• Panhypopituitarism

• Hyperparathyroidism

• Pseudo-hypoparathyroidism

• Pheochromocytoma

• Glucagonoma

Diseases - Neurologic

Central

• Cord lesions

• Cauda equina

• Lumbar disc

disease

• Tabes dorsalis

• Multiple sclerosis

• Parkinsonism

• Stroke

• Brain tumor

Peripheral

• Autonomic

neuropathy

• Diabetes mellitus

• Amyloidosis

• Paraneoplastic

disease

• Chagas' disease

• Neurofibromatosis

• Hirschsprung's

Idiopathic Constipation

Slow transit

• Failure of propulsion through colon

• Primary symptom: infrequent stool

– Once stool in position for evacuation,

expelled relatively easily

• Most common mechanism of

idiopathic constipation

Idiopathic Constipation

Functional outlet obstruction

• Ineffective opening or blockage of

anal canal, or failure of expulsion

• Normal defecation: barriers to

stool evacuation removed

• Normal stool frequency but

difficulty with evacuation

Three Hs: Chronic Constipation

• Hypertonic: diverticulosis, irritable

bowel syndrome

• Hypotonic: neurogenic, dementia /

stroke, diabetic neuropathy, MS,

ALS, cord lesion, psychogenic,

debilitation, Parkinsonism

• Habit: toilet training

U.S. Air Force, Wikimedia Commons

General Physical Exam

• Evaluate for systemic diseases

• Search for organic causes

• Abdomen: usually normal

– May show tenderness, mass,

distention, evidence of obstruction

• Perineum: fissure, inflamed

hemorrhoid, perirectal abscess

Rectal Exam - Most Important!

• Squeezing to prevent defecation

assesses anal sphincter tone

• Bearing down to simulate

defecation relaxes anal sphincter,

puborectalis

– Paradoxical contraction of either

suggests outlet obstruction

Rectal Exam - Most Important!

• Feel for stricture, tumor, mass

• Usually feel large amounts of hard

stool in rectum

– Empty ampulla: obstructive disease

or hypertonic constipation

– Soft, putty-like stools: hypotonic or

habit constipation

Rectal Exam

Palpate the

puborectalis

for bulk,

tension,

tenderness

National Cancer Institute, National Institutes of Health,

Wikimedia Commons

Rectal Exam - Most Important!

• Results may not correlate with

complaint of constipation or with

abdominal radiographs

• Rectal exam alone cannot confirm

or exclude constipation

• Check stool for occult blood: colon

carcinoma vs. strain at stool

X-Rays

• Plain abdominal x-ray: accurately

document colonic loading

– Extent of retention

– Bowel obstruction

– Megacolon

– Volvulus

– Mass lesions

• Stool masses: bubbly or speckled

OpenStax, Wikimedia Commons

X-Rays

Source Undetermined

X-Rays

Not all

abdominal

masses are

stool

Source Undetermined

X-Rays

Source Undetermined

X-Rays

Source Undetermined

Lab Studies

• Indicated only as dictated by the

history and physical examination

• Known diuretics: hypokalemia

• Known carcinoma: hypercalcemia

• Blood: low hemoglobin

• WBC count: not specific or helpful

• Thyroid functions: if suggestive

Chronic Constipation

• Determine specific reason for this

visit

• Provide symptomatic relief

• Refer to private physician for

continued evaluation, therapy

Morbidity and Mortality

• Most bad outcomes: missed

diagnosis of bowel obstruction or

perforation

• Be liberal with x-ray if uncertain

Complications of Constipation

• Nonobstructive (straining at stool,

intrathoracic pressure changes):

hernias, GE reflux, decreased

coronary, cerebral, peripheral

arterial circulation

• Obstructive: fecal impaction,

idiopathic megacolon, volvulus,

intestinal obstruction

Complications of Constipation

Idiopathic Megacolon

Source Undetermined

Complications of Constipation

Megacolon

Source Undetermined

Complications of Constipation

Volvulus

Source Undetermined

Empiric Management

• Eradicate underlying cause

• Provide symptomatic therapy

– Adequate fluid / fiber intake

– If necessary: synthetic bulk agents

Fiber vs. Roughage

• Fiber: primarily from grains and

bran cereals, increases fecal bulk

• Roughage: from most fruits and

vegetables, low bulk

• Psyllium (Metamucil®, Fiberall®)

• Methylcellulose (Citrucel®)

• Both form viscous liquid, promote

peristalsis

Fiber: Side Effects

• Common: flatulence, bloat, cramp

• Bacterial metabolism of bran can

form methane gas

• Bulk agents: require adequate fluid

intake or worsen constipation

• Can decrease absorption of

salicylates, nitrofurantoin,

diuretics, tetracyclines

Lubricants

• Oral mineral oil helpful if acute

painful perianal lesions

• Less painful passage: soft, coated

stool

Lubricants

• Usually well tolerated

• Contraindicated in dysphagia:

aspiration can cause lipid

pneumonia

Stool Softeners

• Docusate: Colace®, Surfak®

• Wetting agents, believed to

enhance fecal moisture content

Stool Softeners

• As effective as placebo, no better

than other methods

• Can be hepato-toxic, enhance

absorption of other liver toxins

• No chronic use

Irritants

• Short-term: benefit if diminished gut motility (constipating drugs, hypokalemia, immobility)

• Chronic use limited to

– Weakened abdominal muscles

– Diminished bowel motility from necessary medications

– Loss of rectal reflexes

– Delayed gut transit or megacolon

Osmotic Agents

• Often used for colon prep for

bowel procedures

• In combination with activated

charcoal to prevent briquettes

Osmotic Agents

• Lactulose: disaccharide formed from one molecule each of the simple sugars fructose and galactose

• Metabolites draw water into bowel, causing cathartic effect through osmotic action

Osmotic Agents

• Sorbitol (AKA glucitol): slowly

metabolized sugar alcohol

• Draws water into large intestine

stimulates bowel movement

Osmotic Agents

• Magnesium hydroxide: Phillips'

Milk of Magnesia®

• Causes fluid retention, distends

colon, increases peristaltic activity

Osmotic Agents

• Decreases

effect of iron

salts, digoxin,

tetracyclines,

indomethacin

• Avoid in renal

failure

Osmotic Agents

• Polyethylene glycol

• Colonic lavage solution used as

bowel prep

• Effective in treating fecal impaction

Suppositories

• Especially helpful in patients with

trouble expelling soft stool

• Glycerine: may be soothing, help

patient with constipation from

painful perianal lesions

Enemas

• Tap-water or oil-retention: helpful

with disimpaction

• Routine use if failed outpatient

laxatives

• Repeated enemas damage

myenteric plexus, cause motility

dysfunction

The Illinois Enema Bandit

The Illinois enema bandit

I heard he’s on the loose

Lord, the pitiful screams

Of all them college-educated women...

Boy, he’d just be tyin’ ’em up

(they’d be all bound down!)

Just be pumpin’ every one of ’em up

with all the bag fulla

The Illinois enema bandit juice

Milk and Molasses

“One of the most powerful enemas

that I have experienced is the "milk

and molasses" enema ("M&M," for

short). Use equal amounts of milk

and the "blackstrap" variety of

molasses (it is a strong-flavored

type often used in baking).”

- continued

Milk and Molasses

“You won't need a large volume; a

pint of each would be sufficient. Put

the milk in a saucepan and bring to

a boil, then add the molasses,

remove from heat, and stir

thoroughly. When the mixture cools

to about 105o, it is ready to

administer.”

Milk and Honey

2 cups milk

16 oz. honey

4 egg whites

“Blend ingredients, then heat in a

small saucepan to 105o. Very nice

for punishment, heavy cramping.”

www.frugaldomme.com

Manual Disimpaction

• May be

acutely

necessary

Source Undetermined

Manual Disimpaction

Source Undetermined Source Undetermined

Manual Disimpaction

Source Undetermined Source Undetermined

Manual Disimpaction

Source Undetermined Source Undetermined

Manual Disimpaction

Source Undetermined

Source Undetermined

Laxative Abuse

3% sodium hydroxide turns stool

red, and hydrochloric acid

reverses red…

…demonstrates phenolphthalein,

most commonly abused laxative

Laxative Abuse

Overzealous laxative use:

• Cathartic colon: "pipe stem"

lacking haustra and mimicking

ulcerative colitis

• Melanosis coli: brown pigment

deposits in mucosa, seen on

endoscopy and colonic biopsy

Artificial Sphincter

Hernan Montez, Wikimedia Commons

Disposition

• Usually can be discharged if

treatment plan in place for acute

constipation, adequate teaching

about prevention

• Fecal impaction, megacolon,

volvulus, bowel obstruction: admit

for further intervention

Disposition

• No apparent cause: treat

symptoms, refer for outpatient

diagnostic evaluation

– Sigmoidoscopy, barium enema (air

contrast) to evaluate for underlying

intrinsic bowel lesion

– Endocrinologic metabolic causes

Conclusions

• Most important part of evaluation

is the history

• Most constipation can be treated

by correcting the “4 Ds” – diet,

deficient fluid intake, deficient fiber

intake, drugs