Gastroenterology
Approach to the patient with constipation
With Kelley Chuang, M.D.
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Learning Objectives
In this lecture, you will learn how to
• provide a differential diagnosis for constipation.
• identify clinical features of bowel obstruction.
• describe the basic management of constipation.
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What Is Constipation?
Constipation is defined by at least 2 of the following:
Straining with defecation Use of manual maneuvers
to facilitate a BM
Passage of lumpy/hard stool
Frequency of less than
Sensation of incomplete 3 BMs/week
defecation
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Who Is Affected?
Constipation affects 25 50% of the general
population, with much higher prevalence in
women, the elderly, and patients in nursing
homes.
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Important Historical Risk Factors to Elicit
Age > 50 years at onset
Rectal bleeding
Unexplained weight loss If multiple risk
factors are
present, consider
Family or personal history of colon cancer colonoscopy!
History of abdominal surgery, cancer, or irradiation
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Types of Constipation
1. Primary constipation 2. Secondary constipation
• Slow transit: prolonged stool • Medications (especially
transit through colon opioids)
• Dyssynergic defecation: • Endocrine or metabolic
difficulty with expelling stool disorders
from anorectum
• Neurologic disorders
• Irritable bowel syndrome:
altered bowel habits with
abdominal pain
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A 63-year-old Woman with Progressive Abdominal Pain Test case
A 63-year-old woman presents to the ED complaining of Abdominal pain, nausea,
progressive abdominal pain, nausea, and vomiting for the vomiting, and absence of
past 2 days. She has not passed a bowel movement for 5 days gas and BMs
and is not passing gas. Her surgical history includes a prior
exploratory laparotomy for a gunshot wound. History of abdominal
surgery
Vitals are significant for a heart rate of 110 beats/min, otherwise
normal. On exam, she has hyperactive bowel sounds, Hyperactive bowel sounds
moderate tenderness to palpation, and no rebound tenderness
or guarding.
What is the best next diagnostic test?
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Woman with Progressive Abdominal Pain Quick Question
What is the significance of the
obstipation?
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Woman with Progressive Abdominal Pain Quick Answer
Obstipation, or the lack of flatus in addition
to constipation, is a concerning symptom
of bowel obstruction.
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Small Bowel Obstruction (SBO)
• Partial (able to pass gas or small BMs) or complete (obstipation)
• Common causes: adhesions from prior surgery, incarcerated hernia, malignancy, IBD, etc.
• Features:
• Crampy abdominal pain
• Nausea and vomiting
• Obstipation
• Diagnosis by abdominal x-ray
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Small Bowel Obstruction (SBO) Management
Partial obstruction Complete obstruction
IV fluids, bowel rest, Surgery
NG tube decompression
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A 63-year-old Woman with Progressive Abdominal Pain Test case
A 63-year-old woman presents to the ED complaining of Abdominal pain, nausea,
progressive abdominal pain, nausea, and vomiting for the vomiting, and absence of
past 2 days. She has not passed a bowel movement for 5 days gas and BMs acute
and is not passing gas. Her surgical history includes a prior obstipation
exploratory laparotomy for a gunshot wound.
History of abdominal
Vitals are significant for a heart rate of 110 beats/min, otherwise surgery
normal. On exam, she has hyperactive bowel sounds,
moderate tenderness to palpation, and no rebound tenderness Hyperactive bowel sounds
or guarding. possible obstruction
What is the best next diagnostic test?
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A 63-year-old Woman with Progressive Abdominal Pain Answer
Test case
A 63-year-old woman presents to the ED complaining of Abdominal pain, nausea,
progressive abdominal pain, nausea, and vomiting for the vomiting, and absence of
past 2 days. She has not passed a bowel movement for 5 days gas and BMs acute
and is not passing gas. Her surgical history includes a prior obstipation
exploratory laparotomy for a gunshot wound.
History of abdominal
Vitals are significant for a heart rate of 110 beats/min, otherwise surgery
normal. On exam, she has hyperactive bowel sounds,
moderate tenderness to palpation, and no rebound tenderness Hyperactive bowel sounds
or guarding. possible obstruction
What is the best next diagnostic test?
Answer: The best diagnostic test is an abdominal x-ray
(also known as a KUB)
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78-year-old Dementia Test case
A 78-year-old man with disease and dementia is Neurologic disorder that
brought to the ED from his nursing home for complaints of may impact stool transit,
abdominal pain for the past day. He has not passed a bowel nursing home high risk for
movement in a week. He takes hydrocodone-acetaminophen constipation
for chronic back pain.
Chronic opioid use
Vitals are normal. On exam, he grimaces to palpation in the
lower quadrants of his abdomen, but there is no rebound
tenderness or guarding. A digital rectal exam notes impacted
stool in the rectum. Fecal impaction on exam
What is the best next step in management?
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Paralytic Ileus
• Disruption in normal GI tract motility
• Risk factors:
• Recent surgery
• Medications (opioid use)
• Intraabdominal inflammation
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Paralytic Ileus
• Clinical features:
• May be difficult to differentiate from SBO
• Abdominal distension, abdominal pain,
nausea/vomiting, constipation
• Hypoactive bowel sounds on eXam
• Diagnosis: abdominal x-ray shows dilated bowel loops
Dilated bowel loops,
air in rectum
© 2008 Goyal and Srivastava; licensee BioMed Central Ltd., Figure 1, [Link]
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Quick Clinical Question
How do you differentiate between paralytic
ileus and small bowel obstruction?
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How Do you Differentiate Between SBO and Ileus?
Small bowel obstruction (SBO) Paralytic ileus
Bowel sounds Hyperactive or absent Hypoactive or absent
Peritoneal signs May be present Absent
Imaging Dilated bowel loops Dilated bowel loops
Air-fluid levels No air-fluid levels
No air in rectum Air in rectum
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General Treatment of Constipation: Principles
Initial Pharmacologic
Lifestyle and dietary changes: • Fiber supplements
• Increase dietary fiber • Osmotic laxatives
• Increase physical activity • Stimulants
Severe cases
• Patients with fecal impaction (stool stuck in the rectum)
may need manual disimpaction or enema for relief.
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General Treatment of Constipation: Medications
Drug type Examples Mechanism of action
Fiber supplement Psyllium Increase dietary fiber for
Methylcellulose stool bulking
Osmotic laxative Magnesium hydroxide Poorly absorbed or
Lactulose nonabsorbable sugars that
Sorbitol draw water into colon
Polyethylene glycol
Stimulant laxative Senna Stimulate intestinal motor
Bisacodyl activity
Prosecretory agents Linaclotide Increase colonic secretions
Lubiprostone
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78-year-old Man with Test case
A 78-year-old man with disease and dementia is Neurologic disorder that
brought to the ED from his nursing home for complaints of may impact stool transit,
abdominal pain for the past day. He has not passed a bowel nursing home high risk for
movement in a week. He takes hydrocodone-acetaminophen constipation
for chronic back pain.
Chronic opioid use
Vitals are normal. On exam, he grimaces to palpation in the
lower quadrants of his abdomen, but there is no rebound
tenderness or guarding. A digital rectal exam notes impacted
stool in the rectum. Fecal impaction on exam
What is the best next step in management?
Led Joestar, pifeli2160@[Link]
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78-year-old Man with Dementia Answer
Test case
A 78-year-old man with dementia is Neurologic disorder that
brought to the ED from his nursing home for complaints of may impact stool transit,
abdominal pain for the past day. He has not passed a bowel nursing home high risk for
movement in a week. He takes hydrocodone-acetaminophen constipation
for chronic back pain.
Chronic opioid use
Vitals are normal. On exam, he grimaces to palpation in the
lower quadrants of his abdomen, but there is no rebound
tenderness or guarding. A digital rectal exam notes impacted
stool in the rectum. Fecal impaction on exam
What is the best next step in management?
Answer: Fecal disimpaction or enema
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Learning Outcomes
In this lecture, you have learned how to
provide a differential diagnosis for
constipation.
identify clinical features of bowel
obstruction.
describe the basic management of
constipation.
Led Joestar, pifeli2160@[Link]
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This document is a property of: Led Joestar
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.
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