RESIDENTS’ CLINIC

75-Year-Old Woman With Abdominal Pain

and Constipation
Chineze Akusoba, MD; Anthony Robateau, MD; and Victor Chedid, MD

A
75-year-old woman presented to to 145 mmol/L); potassium, 3.6 mmol/L See end of article
the emergency department with (3.6 to 5.2 mmol/L); alkaline phosphatase, for correct answers
a 1-year history of worsening loose 100 U/L (40 to 129 U/L); aspartate amino- to questions.
stools and abdominal discomfort. Over the transferase, 32 U/L (8 to 48 U/L); alanine Resident in Internal Medicine,
course of the year, the patient had experi- aminotransferase, 30 U/L (7 to 55 U/L); total Mayo Clinic School of Grad-
enced regular cycles of liquid stool followed bilirubin, 0.4 mg/dL (1.2 mg/dL); direct uate Medical Education,
Rochester, MN (C.A., A.R.);
by constipation for the next few days. She bilirubin, 0.2 mg/dL (0.3 mg/dL); creati- Advisor to residents and
had recently started taking loperamide on nine, 1.2 mg/dL (0.59 to 1.04 mg/dL); blood Consultant in Gastroenter-
ology and Hepatology, Mayo
the days she had diarrhea as recommended urea nitrogen, 23 mg/dL (6 to 24 mg/dL);
Clinic, Rochester, MN (V.C.).
by her primary care provider. She denied lactate, 1.6 mmol/L (0.5 to 1 mmol/L); and
hematochezia, melena, nocturnal stooling, lipase, 49 U/L (13 to 60 U/L).
weight loss, or recent travel. She had
a normal screening colonoscopy 4 years 1. Based on the patient’s clinical history,
prior. Past medical history was notable for which one of the following is the most
Alzheimer dementia, type 2 diabetes melli- likely explanation for the patient’s
tus, hypertension, hyperlipidemia, and oste- symptoms?
oarthritis. Medications included metformin, a. Fecal impaction with overflow diarrhea
lisinopril, atorvastatin, and acetaminophen. b. Colorectal cancer
There were no recent medication changes. c. Metformin side effect
She is a resident of a long-term care facility. d. Inflammatory bowel disease (IBD)
Physical examination revealed a frail e. Clostridioides difficile enterocolitis
elderly woman with body mass index of
17.4 kg/m2. The patient was afebrile and he- This patient’s altered bowel habits of
modynamically stable with a blood pressure chronic constipation intermixed with diar-
of 122/68 mm Hg, heart rate of 84 beats/ rhea and fecal incontinence are suspicious
min, and oxygen saturation of 99% on for a fecal impaction with overflow diarrhea.
ambient air. Mucus membranes were dry In elderly patients with dementia, paradoxi-
and she had poor skin turgor. Cardiopulmo- cal diarrhea and incontinence may be among
nary examination was unremarkable. the most common presenting symptoms in
Abdominal exam revealed a mildly distended patients with fecal impaction.1
abdomen with a palpable mass in the right Although the patient presents with
lower quadrant that was firm and tender to a persistent change in her bowel habits, she
palpation. There was no rebound or guard- does not have rectal bleeding, anemia, or un-
ing. Bowel sounds were hypoactive. explained weight loss that would be suspi-
Initial laboratory evaluation revealed the cious for colorectal cancer. In addition, the
following (reference ranges provided paren- patient had a normal colonoscopy 4 years
thetically): hemoglobin, 13.6 g/dL (12 to prior. Given these findings, the likelihood
15.5 g/dL) with a mean corpuscular volume of colorectal cancer in this patient is low.
of 94.5 fL (80 to 100 fL); leukocytes, Diarrhea is a very common side effect
5.410⁹/L (3.4 to 9.610⁹/L) with a normal associated with the initiation or uptitration
differential; platelet count, 24810⁹/L (157 of metformin. The patient has been on met-
to 37110⁹/L); sodium, 147 mmol/L (135 formin for a long time without any recent

Mayo Clin Proc. n January 2022;97(1):165-169 n https://doi.org/10.1016/j.mayocp.2021.04.030 165

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 MAYO CLINIC PROCEEDINGS

dose adjustments that would explain her This problem is amplified when natural daily
diarrhea. In addition, this does not explain routines become disturbed, as is often the
her underlying severe constipation with case in institutions.1 Among residents of
palpable right lower quadrant mass. long-term care facilities, more than half are
Inflammatory bowel disease is a chronic afflicted with constipation.3
inflammatory condition of the gut that in- There are numerous medications that
cludes ulcerative colitis and Crohn disease.2 contribute to constipation and medication
Patient’s with IBD generally present with reconciliation should always be performed
persistent diarrhea, usually with blood and in patients presenting with chronic constipa-
mucous.2 Additional symptoms include tion.1,4 The patient is on several medications
abdominal discomfort, fecal urgency, which could increase her risk of constipa-
tenesmus, weight loss, fever, and anemia. tion, most notably, loperamide. However,
Symptoms vary depending on the extent loperamide is a recent addition to the pa-
and severity of disease.2 Constipation is tient’s medication regimen and the patient
less likely to be a presenting symptom of has longstanding constipation making poly-
IBD. Although the patient does have abdom- pharmacy less likely to be the predominant
inal discomfort with loose stools, she does risk factor.
not present with additional features of the Constipation is considered a common
disease. Furthermore, the patient’s screening problem in patients with diabetes secondary
colonoscopy 4 years prior was without find- to autonomic neuropathy leading to
ings suggestive of IBD. increased colonic transit time and the
Clostridioides difficile enterocolitis absence of the gastrocolonic reflex.5 Studies
commonly presents as loose stools with asso- have suggested only a weak association be-
ciated abdominal cramping and tenderness. It tween diabetes and constipation in the gen-
can cause very severe dehydration and eral population.5
require hospitalization. It is common in The patient’s age is the most critical risk
elderly patients and patients in long-term factor associated with the development of sig-
care facilities and generally occurs after use nificant constipation. In patients older than
of antibiotics. Clostridioides difficile does not the age of 75 years, constipation is twice as
explain the underlying constipation in this frequent as in those younger than the age of
patient. 75 years.6 This population is at increased
The patient’s physical exam and mild risk of constipation because they are more
hypernatremia suggested she was dehydrated. likely to have low-fiber diets, poor fluid
She was started on intravenous fluids. intake, poor dentition leading to mastication
difficulties and subsequent poor oral intake,
2. Which one of the following is the greatest immobility, and constipation-inducing
risk factor for the patient’s underlying medications.7
condition? Thorough medication reconciliation was
a. Alzheimer dementia performed to identify any additional agents
b. Resident of a long-term care facility that could contribute to constipation, but
c. Polypharmacy no additional medications were identified.
d. Diabetes Further workup was initiated.
e. Age
3. What is the next best diagnostic tool
There are many factors associated with based on the patient’s clinical history,
the occurrence of severe, chronic constipa- exam, and laboratory findings?
tion. The risk of constipation is increased a. Digital rectal examination (DRE)
in patients with dementia and patients in b. Abdominal plain radiogram
long-term care facilities.3 Among patients c. Computed tomography of the abdomen
with dementia, neglecting the urge to defe- and pelvis (CT A/P) with intravenous and
cate contributes to worsening constipation. oral contrast
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RESIDENTS’ CLINIC

d. Colonoscopy vault through the distal colon. There were

e. Right upper quadrant ultrasound no findings suggestive of bowel perforation.

A DRE is critical to confirm the diagnosis 4. What is the best initial treatment option
of fecal impaction. A gentle rectal examina- to be considered at this point?
tion is generally well tolerated, safe, and pro- a. Loperamide
vides the ability to detect most fecal b. Polyethylene glycol
impactions. Astute clinicians should c. Magnesium citrate
remember that the absence of palpable stool d. Manual disimpaction
on DRE does not rule out the diagnosis of a e. Enema
fecal impaction. Given that fecal impactions
can occur anywhere in the colon, a more Fecal impactions generally occur in the
proximal impaction must be considered if rectum and may result in the overflow of
no stool is palpated on DRE. Additionally, liquid stool around the impacted fecal
alternative diagnoses such as colonic stric- mass. Because of the paradoxical diarrhea,
tures or volvulus should also be considered. fecal impactions are often initially misdiag-
If fecal impaction is suspected, but the nosed and providers mistakenly recommend
DRE is negative, plain abdominal radiog- the use of an antidiarrheal medication as in
raphy to evaluate for masses of stool or signs this case.2 In patients with a fecal impaction,
of obstruction is indicated. Plain abdominal antidiarrheal medications such as lopera-
radiography may reveal fecal overloading of mide not only are ineffective but conversely
the colon with colonic distension in the worsen the impaction.
segment proximal to the location of the fecal Efforts to remove a fecal impaction from
impaction.1,3 The most informative radio- above are ineffective and can worsen the
logic study for evaluation of fecal impaction abdominal pain and contribute to complica-
is a CT A/P.3 Computerized tomography al- tions if complete obstruction is identified.1
lows for quick assessment of potential com- However, for fecal impactions with partial
plications of impaction and allows for obstruction and proximal impactions unable
visualization of extracolonic structures that to be reached by digital palpation, laxatives
may contribute to constipation. can be used when conditions like volvulus
Endoscopic examination of the colon to and small bowel obstruction have been ruled
evaluate for neoplasm is generally indicated out.3,8 The ideal laxative of choice is gener-
at least once, notably if the patient presents ally polyethylene glycol followed by magne-
with weight loss, anemia, or fecal occult sium citrate.3
blood.1 This patient had a normal colonos- Manual disimpaction is the best first
copy 4 years prior and does not have any treatment step if stool can be palpated on
additional red flag symptoms that would rectal exam.1,3,6,8 The procedure is best per-
necessitate colonoscopy in the acute setting. formed with ample lubrication with progres-
A right upper quadrant ultrasound is sive anal dilation with first one and then two
of low diagnostic yield in the patient fingers. A scissoring motion should be
who presents with constipation, diffuse attempted to fragment the fecal mass. An
abdominal pain, and without liver enzyme anoscope with suction can be used to assist
abnormalities. with disimpaction.1,3 Patients will often
The patient underwent DRE that find immediate relief following disimpaction.
revealed the presence of hard stool in the Once fragmentation and partial expulsion of
rectal vault with surrounding liquid fecal the fecal mass has occurred, enemas and
matter. Following the rectal examination, suppositories may be used.1 A tap-water
she also underwent CT A/P with oral and enema is acceptable, but in elderly patients
intravenous contrast which revealed signifi- the volume should be small and directed to
cant stool burden extending from the rectal the site of obstruction.1

Mayo Clin Proc. n January 2022;97(1):165-169 n https://doi.org/10.1016/j.mayocp.2021.04.030 167

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 MAYO CLINIC PROCEEDINGS

The patient underwent manual disimpac- as lifestyle modifications as the best step
tion with significant improvement in her to prevent recurrent severe constipation
abdominal distension and pain. The patient complicated by fecal impaction.
did well and was able to be discharged to Linaclotide is approved in the treatment
her long-term care facility. of constipation-predominant irritable bowel
syndrome and chronic idiopathic constipa-
5. In the outpatient setting, which one of tion.9 Many patients can achieve relief of
the following is the most appropriate constipation with lifestyle modifications
next step to prevent recurrent fecal and an over-the-counter bowel regimen.
impaction? These measures should be implemented
a. Continuation of antidiarrheal (eg, before consideration of linaclotide for the
loperamide) treatment of constipation.9
b. Discontinuation of metformin In very rare circumstances of fecal
c. Lifestyle modifications and bowel regimen impaction complicated by perforation lead-
d. Linaclotide ing to peritonitis, surgical resection of the
e. Surgical resection involved colon or rectum is indicated.8
This patient does not have evidence of bowel
Unfortunately, recurrent fecal impaction perforation and surgery should not be pur-
is very common in the elderly and institu- sued at this time.
tionalized patients.3 There are numerous The patient was started on a high-fiber
medications that can contribute to fecal diet with adequate fluid intake. At the pa-
impaction and the importance of such tient’s 1-month follow-up appointment, she
cannot be overemphasized. The most reported every other day bowel movements.
notable medications that have been impli- She denied difficulty passing stools or strain-
cated in the development of fecal impaction ing with defecation.
include opiates; antidepressants (ie, tricy-
clic antidepressants); antihypertensives DISCUSSION
that have alpha-adrenergic, beta-adrenergic, Constipation is a common problem in the
or calcium-channel-blocking properties; di- Western world with an average of 2.5
uretics; nonsteroidal anti-inflammatory million physician visits per year.10 Constipa-
drugs; and iron supplements.1,4 The patient tion is generally defined as two or fewer
should avoid antidiarrheal medications, bowel movements in 1 week, straining with
such as loperamide, which would further defecation, hard stools, or the feeling of
worsen the constipation. Diarrhea, not con- incomplete evacuation.10 The prevalence is
stipation, is a known common side effect of greater in the elderly, women, and non-
metformin and the patient’s risk of recur- whites.10 The incidence is increased in pa-
rent fecal impaction would not be mini- tients in nursing homes and extended-care
mized by discontinuation of this facilities. Given the high prevalence in these
medication. patient populations, there is a significant
A bowel regimen should be initiated for cost burden to the health care system in
patients at high risk of constipation. Pa- the prevention, diagnosis, and treatment of
tients should be encouraged to have constipation. Early initiation of therapy is
adequate fluid intake, supplemental fiber, critical in preventing increased morbidity
and stool softeners. Lifestyle modifications and mortality from complications.
to retrain the bowel, such as increased exer- A thorough history and physical examina-
cise and scheduled time after meals for defe- tion are necessary to assist in a differential
cation are also recommended. These diagnosis and aid additional workup and
patients should then be monitored with therapies needed. The causes of constipation
ideally one bowel movement every 1 to 2 are considered in two categories: primary
days.1,4 This patient would benefit most and secondary.7 A number of primary causes
from initiation of a bowel regimen as well are particularly common among the elderly
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RESIDENTS’ CLINIC

including inadequate fiber and fluid intake, constipation.7 If symptoms do not improve,
immobility, poor dentition and mastication a trial of linaclotide or lubiprostone may be
worsening already poor oral intake, and appropriate.11
poor abdominal musculature making it diffi- In summary, constipation and its compli-
cult for the patient to increase intra- cations occur frequently, particularly in the
abdominal pressure to sufficiently perform elderly population. A careful evaluation
Valsalva maneuver.7 Secondary etiologies of may detect the etiology, but often the cause
constipation may require specific treatment will be idiopathic. Because of the increased
and signify more serious underlying pathol- morbidity and reduced quality of life, ther-
ogy.7 In the elderly, common secondary etiol- apy is needed to provide symptomatic relief
ogies include intrinsic bowel lesions (eg, and prevent complications.
carcinoma or diverticular disease), drugs, Potential Competing Interests: The authors report no po-
and neurologic diseases such as Parkinson tential competing interests.
disease, depression, and hypothyroidism.7
Correspondence: Address to Victor Chedid, MD, Division
Once the initial evaluation has been
of Gastroenterology and Hepatology, Mayo Clinic, 200 First
completed and there are no obvious meta- St SW, Rochester, MN, 55905 ([email protected];
bolic, neurologic, or mechanical/obstructive Twitter: @VictorChedidMD).
etiologies, physiologic tests should be consid-
ered.10 These studies should be directed to-
ward patients with rectal outlet delay or
REFERENCES
infrequent defecation.10 Even after significant
1. Wrenn K. Fecal impaction. N Engl J Med. 1989;321(10):658-
testing, the etiology will often remain un- 662.
known, at which point the etiology of the 2. Sairenji T, Collins KL, Evans DV. An update on inflammatory
constipation is considered idiopathic.10 bowel disease. Prim Care. 2017;44(4):673-692.
3. Setya A, Mathew G, Cagir B. Fecal Impaction. Treasure Island. FL:
There are many complications associated StatPearls Publishing Ltd; 2021.
with constipation ranging from benign to life 4. Prather CM, Ortiz-Camacho CP. Evaluation and treatment of
threatening, including hemorrhoids, anal fis- constipation and fecal impaction in adults. Mayo Clin Proc. 1998;
73(9):881-886. quiz 7.
sures, fecal impaction, intestinal obstruction, 5. Talley NJ, Jones M, Nuyts G, Dubois D. Risk factors for chronic
and excessive defecatory strain leading to constipation based on a general practice sample. Am J Gastro-
enterol. 2003;98(5):1107-1111.
circulatory problems.10 Treatment should 6. Dzierzanowski T, Cialkowska-Rysz A. The occurrence and risk
be initiated before the development of com- factors of constipation in inpatient palliative care unit patients vs.
nursing home residents. Prz Gastroenterol. 2018;13(4):299-304.
plications. Initial management is conserva-
7. Alessi CA, Henderson CT. Constipation and fecal impaction in
tive with the addition of dietary fiber (25 the long-term care patient. Clin Geriatr Med. 1988;4(3):571-588.
to 30 g per day), adequate hydration, mobi- 8. Obokhare I. Fecal impaction: a cause for concern? Clin Colon
Rectal Surg. 2012;25(1):53-58.
lization, toilet training, and limiting use of 9. Lacy BE, Schey R, Shiff SJ, et al. Linaclotide in chronic idiopathic
constipating drugs.7 If lifestyle modifications constipation patients with moderate to severe abdominal
do not produce sufficient results, osmotic bloating: a randomized, controlled trial. PLoS One. 2015;10(7):
e0134349.
laxatives, such as polyethylene glycol or 10. De Lillo AR, Rose S. Functional bowel disorders in the geriatric
magnesium citrate should next be consid- patient: constipation, fecal impaction, and fecal incontinence.
Am J Gastroenterol. 2000;95(4):901-905.
ered, followed by a stool softener, such as
11. Mounsey A, Raleigh M, Wilson A. Management of constipation
docusate sodium, and then stimulant laxa- in older adults. Am Fam Physician. 2015;92(6):500-504.
tives.7,11 Suppositories and enemas can also
be considered in the management of chronic CORRECT ANSWERS: 1. a. 2. e. 3. a. 4. d. 5. c.

Mayo Clin Proc. n January 2022;97(1):165-169 n https://doi.org/10.1016/j.mayocp.2021.04.030 169

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