Constipation

Chapter 32


Constipation




Perspective


The term constipation refers to a symptom or complex of symptoms and not a specific diagnosis. Patients and health care providers often define constipation differently. Most health care providers define constipation based on stool frequency. Patients often use the term constipation to describe a broad set of complaints, including straining, hard or infrequent stools, pain during a bowel movement, a feeling of incomplete evacuation, or abdominal bloating. Constipation may be acute (new for the patient) or chronic. Chronic constipation is defined as the presence of symptoms for at least 3 months. In clinical practice, attempting to identify the cause of the symptoms will often result in the best chance of effective treatment and will help determine disposition. A definitive diagnosis often is not possible in the emergency department (ED), and appropriate follow-up evaluation should be arranged in those cases. When constipation becomes severe with constant pain, some clinicians use the term obstipation. Obstipation represents the progression of the symptom of constipation toward bowel obstruction.


In the ED, the complaint of constipation should be of concern when it represents a significant change from a patient’s own normal pattern that is creating discomfort for the patient. This change may manifest as a decrease in frequency of defecation, sudden and persistent change in the character or amount of stools (especially decrease in stool caliber), blood in the stool, or problems expelling the stool.1



Epidemiology


The prevalence of constipation varies worldwide. In North America the prevalence is approximately 16%.2 In adults, constipation is more common in women, the elderly, those with high body mass index, and those with low socioeconomic status.2 A consistent trend of increasing prevalence of constipation is observed with age, with significant increases after the age of 70 years. The high prevalence among elderly patients is multifactorial and related to a diet low in fiber, sedentary habits, multiple medications, and various disease processes that impair neurologic and motor control.




Diagnostic Approach



Differential Considerations


The causes of constipation are numerous. Causes of constipation can be divided into primary (no apparent external cause) and secondary causes (summarized in Box 32-1). These two groupings have some overlap. In the ED, patients most commonly have acute constipation resulting from side effects of medications or avoidance of defecation secondary to presence of painful perianal lesions such as fissures, hemorrhoids, or perirectal abscesses.



BOX 32-1


Causes of Constipation





Adapted from Chatoor D, Emmanuel A: Constipation and evacuation disorders. Best Pract Res Clin Gastroenterol 2009; 23:517.



Pivotal Findings



History


A thorough, detailed history usually identifies the most likely cause of the patient’s constipation. Defining what the patient means by “constipation” is a good starting point. Essential information includes the presence or absence of signs or symptoms that the American College of Gastroenterology terms “alarm symptoms.” These include fever, anorexia, nausea, vomiting, blood in the stool, anemia, weight loss of more than 10 lb, a family history of colon cancer, onset of constipation after the age of 50, and acute onset of constipation in an elderly patient.1


Additional elements of the history are directed toward elucidating a possible cause. Questions about the character of the stools may reveal a decrease in caliber of the stool, suggesting possible mass lesion, or diarrhea alternating with constipation, which may indicate irritable bowel syndrome. Frequency of stools and what the patient considers “normal” should be assessed.


The review of systems may need to include questions regarding associated symptoms if no obvious cause is elicited in the cursory history. Questions directed at associated neurologic symptoms, activity level, and status of comorbid diseases may provide clues to contributing factors.


A medication history is essential and should include any recent changes in dosage of any prescription medications, herbal agents, and over-the-counter (OTC) medications. Many patients experience constipation as a side effect of medication. Drugs of abuse also may cause changes in bowel patterns. Opioid medications are the most common cause of constipation among medications and drugs of abuse. Because of this, elderly patients who are prescribed opiates from the ED for home use should be warned about constipation and given instructions to prevent and treat it.

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Jul 26, 2016 | Posted by in ANESTHESIA | Comments Off on Constipation

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