2011
Resolution
Diagnosis
The patient has constipation (Figure 2).
Learnings
Constipation includes primary motor (neurologic) disorders, defecation disorders, and adverse effects of medications. Constipation is defined by the American Gastroenterological Association as difficult or infrequent passage of stool, hard stool, or a feeling of incomplete evacuation. Prevalence in adults ranges between 2% and 27%, with up to 74% of nursing-home residents using daily laxatives. Constipation-predominant irritable bowel syndrome is abdominal discomfort with two of these three symptoms: relief of pain after defecation, hard stools, or less-frequent stools.
Treatment
- Exclude secondary causes of constipation.
- Hydrate the patient.
- Instruct the patient to increase intake of dietary fiber.
- Consider the following medications for the patient:
- Polyethylene glycol (MiraLAX)—osmotic
- Docusate (Colace)—stool softener
- Psyllium (Metamucil)—fiber
- Magnesium hydroxide (milk of magnesia)—saline cathartic
- Mineral oil—lubricant
- Lactulose—osmotic
- Bisacodyl (Dulcolax)—stimulant cathartic
Indications for Transfer to an Emergency Department
- Uncertain diagnosis
- Intractable pain
- Unstable vital signs
- Concurrent abdominal pain in elderly patients
- Presence of red flag symptoms such as the following:
- Blood in the stool
- Vomiting
- Weight loss
- History of previous surgeries
- A medical history of malignancy
Figure 1 is by James Heilman, MD, from https://commons.wikimedia.org/wiki/File%3AConstipation.JPG. Figure 2 is modified from Figure 1. The original image is used with permission under a Creative Commons Attribution 3.0 Unported license, which allows adaptation of the image: https://creativecommons.org/licenses/by/3.0/deed.en.