The Patient with Constipation

1
The Patient with Constipation

• Joe Lex, MD, FAAEM
• Temple University Hospital
• Philadelphia, PA

2
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
3
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

Objectives
4
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

Words
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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

Words
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Some Definitions

• Epsom Salts sulphate of magnesia having
  cathartic qualities originally prepared by
  boiling down the mineral waters at Epsom, England
  (home of racetrack)

Words
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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

The Past
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Defecation in History

• Ebers Papyrus five intestinal stimulants - figs,
  castor oil, seed oil, aloes, and sweet beer

The Past
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Defecation in History

• Hippocrates All diseases are resolved either by
  the mouth, the bowels, the bladder

The Past
10
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...

The Past
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John Harvey Kellogg, MD
The Past
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Intestinal Autointoxication

• Definition self-poisoning from from ones own
  retained waste
• (The constipated person) is always working
  toward his own destruction he makes continual
  attempts at suicide by intoxication.
• - Charles Bouchard, 1906

Quackery
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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

Quackery
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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.

Quackery
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Intestinal Autointoxication
Quackery
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Intestinal Autointoxication
Quackery
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Intestinal Autointoxication
Quackery
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Intestinal Autointoxication

• Sir William Arbuthnot Lane of Guys Hospital,
  London performed hundreds of colectomies to rid
  patients of the cause of all the hideous
  sequence of maladies peculiar to civilization.

Quackery
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Constipation Is a Symptom...

• ...not a diagnosis
• Usually need to identify cause to effect proper
  treatment
• Definitive diagnosis often not possible in ED

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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

Definition
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Frequent Self-Diagnosis

• Often self-diagnosed and treated
• gt700 OTC laxatives
• Sales more than 1,000,000,000 per year in US

Definition
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Frequent Self-Diagnosis

• Patients put premium on regularity
• Concern when significant change from normal
  pattern

Definition
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Epidemiology

• 20 of population complains of at least one
  episode constipation
• 98 are elderly
• 26 of elderly men
• 34 of elderly women affected
• 2,500,000 visits yearly to health care providers

Epidemiology
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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.

Epidemiology
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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

Physiology
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Normal Physiology

• Water passively absorbed follows osmotic
  gradient produced by sodium absorption
• Sodium actively absorbed even against large
  concentration gradients

Physiology
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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 increases intraluminal pressure

Physiology
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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)

Physiology
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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

Physiology
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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

Physiology
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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

Physiology
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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

Physiology
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Most Important Factor

• Diet, especially adequate fluid and fiber intake

Physiology
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Pivotal Findings History

• Thorough, detailed history usually identifies
  most likely cause
• Define what patient means by constipation

History
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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

History
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Pivotal Findings History
History
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Associated Symptoms

• Job, sleep habits, appetite, daily activities,
  depression
• Flatulence and bloating consider malabsorption
  syndrome

History
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Associated Symptoms

• Temperature elevation invasive infection,
  inflammatory disease, prolonged fecal impaction

History
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Associated Symptoms
History
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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)

History
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Associated Symptoms

• Abdominal pain
• Location and character may localize specific
  disease process
• Not diagnostic of constipation
• May be dull, crampy, and visceral

History
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Associated Symptoms

• Excessive gas
• Anorexia
• Fatigue
• Headache
• Low back pain
• Weakness
• Restlessness

History
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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

History
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Four Ds of Constipation

• Diet
• Deficient fluid intake
• Deficient fiber intake
• Drugs

History
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Drugs Causing Constipation

• Anticholinergics antihistamines, tricyclic
  anti-depressants, phenothiazines,
  antiparkinsonian agents, antispasmodics
• Antacids AlOH, CaCO3
• Antihypertensives diuretics, CCBs, clonidine

History
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Drugs Causing Constipation

• Narcotics
• Sympathomimetics ephedrine, terbutaline
• Laxative abuse
• NSAIDs
• Others iron, phenytoin, barium, bismuth,
  sucralfate, etc.

History
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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

History
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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

History
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Herbals and Alternatives
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Physical Causes

• Immobility, lack of exercise
• Travel
• Psychosocial stress, depression, psychosis
• Failure to respond to the urge to defecate

History
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Diseases - Anatomic

• Painful perianal lesion fissures, hemorrhoids,
  abscesses, herpes
• Intrinsic bowel lesions carcinoma,
  diverticulitis, obstruction

History
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Diseases - Metabolic

• Diabetes mellitus
• Hypercalcemia
• Hypokalemia
• Porphyria

History
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Diseases - Endocrine

• Hypothyroidism
• Panhypopituitarism
• Hyperparathyroidism
• Pseudo-hypoparathyroidism
• Pheochromocytoma
• Glucagonoma

History
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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

History
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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

History
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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

History
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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

History
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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

Physical
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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

Physical
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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

Physical
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Rectal Exam
Palpate the puborectalis for bulk, tension,
tenderness
Physical
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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

Physical
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X-Rays

• Plain abdominal x-ray accurately document
  colonic loading
• Extent of retention
• Bowel obstruction
• Megacolon
• Volvulus
• Mass lesions
• Stool masses bubbly or speckled

Radiograph
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X-Rays
Radiograph
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X-Rays

• Not all abdominal masses are stool

Radiograph
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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

Lab studies
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Chronic Constipation

• Determine specific reason for this visit
• Provide symptomatic relief
• Refer to private physician for continued
  evaluation, therapy

Treatment
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Morbidity and Mortality

• Most bad outcomes missed diagnosis of bowel
  obstruction or perforation
• Be liberal with x-ray if uncertain

M M
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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
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Complications of Constipation
Complications
Idiopathic Megacolon
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Complications of Constipation
Megacolon
Complications
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Complications of Constipation
Volvulus
Complications
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Treatments
Treatment
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Treatment
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Empiric Management

• Eradicate underlying cause
• Provide symptomatic therapy
• Adequate fluid / fiber intake
• If necessary synthetic bulk agents

Treatment
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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

Treatment
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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

Treatment
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Lubricants

• Oral mineral oil helpful if acute painful
  perianal lesions
• Less painful passage soft, coated stool

Treatment
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Lubricants

• Usually well tolerated
• Contraindicated in dysphagia aspiration can
  cause lipid pneumonia

Treatment
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Stool Softeners

• Docusate Colace, Surfak
• Wetting agents, believed to enhance fecal
  moisture content

Treatment
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Stool Softeners

• As effective as placebo, no better than any
  others
• Can be hepato-toxic, enhance absorption of other
  liver toxins
• No chronic use

Treatment
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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

Treatment
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Osmotic Agents

• Often used for colon prep for bowel procedures
• In combination with activated charcoal to prevent
  briquettes

Treatment
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Osmotic Agents

• Nonabsorbable sugars lactulose or sorbitol
  mainstay treatment for chronic constipation

Treatment
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Osmotic Agents

• Magnesium hydroxide Phillips' Milk of Magnesia
• Causes fluid retention, distends colon, increases
  peristaltic activity

Treatment
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Osmotic Agents

• Decreases effect of iron salts, digoxin,
  tetracyclines, indomethacin
• Avoid in renal failure

Treatment
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Osmotic Agents

• Polyethylene glycol
• Colonic lavage solution used as bowel prep
• Effective in treating fecal impaction

Treatment
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Suppositories

• Especially helpful in patients with trouble
  expelling soft stool
• Glycerine may be soothing, help patient with
  constipation from painful perianal lesions

Treatment
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Enemas

• Tap-water or oil-retention helpful with
  disimpaction
• Routine use if failed outpatient laxatives
• Repeated enemas damage myenteric plexus, cause
  motility dysfunction

Enemas
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Enema Lore

• www.frugaldomme.com
• www.enema-web.com

Enemas
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The Illinois Enema Bandit

• The Illinois enema bandit
• I heard hes on the loose
• Lord, the pitiful screams
• Of all them college-educated women...
• Boy, hed just be tyin em up
• (theyd be all bound down!)
• Just be pumpin every one of em up with all the
  bag fulla
• The Illinois enema bandit juice

Enemas
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Milk and Molasses

• One of the most powerful enemas that I have
  experienced is the "milk and molasses" enema
  ("MM," for short). Use equal amounts of milk
  and the "blackstrap" variety of molasses (it is a
  strong-flavored type often used in baking).
• - continued

Enemas
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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.

Enemas
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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

Enemas
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Manual Disimpaction

• May be necessary acutely

Treatment
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Manual Disimpaction
Treatment
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Manual Disimpaction
Treatment
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Manual Disimpaction
Treatment
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Manual Disimpaction
Treatment
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Laxative Abuse

• 3 sodium hydroxide turns stool red, and
  hydrochloric acid reverses red
• demonstrates phenolphthalein, most commonly
  abused laxative

Abuse
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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

Abuse
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Artificial Sphincter
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Happy Sphincter
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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
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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

Disposition
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Flexible Sigmoidoscopy
Disposition