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GEMC- The Adult Patient with Constipation- Resident Training

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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, …

This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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  • 1. Project: Ghana Emergency Medicine Collaborative Document Title: The Adult Patient With Constipation Author(s): Joe Lex, MD, FACEP, FAAEM, (Temple University) 2013 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  • 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  • 3. The Patient with Constipation Joe Lex, MD, FAAEM Temple University Hospital Philadelphia, PA
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. Some Definitions Epsom Salts: sulphate of magnesia having cathartic qualities; originally prepared by boiling down the mineral waters at Epsom, England (home of racetrack)
  • 9. 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
  • 10. Defecation in History • Ebers Papyrus: five intestinal stimulants - figs, castor oil, seed oil, aloes, and sweet beer
  • 11. Defecation in History • Hippocrates: “All diseases are resolved either by the mouth, the bowels, the bladder…”
  • 12. 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...
  • 13. “Intestinal Autointoxication” Definition: self-poisoning from from one’s own retained waste (The constipated person) “…is always working toward his own destruction; he makes continual attempts at suicide by intoxication.” - Charles Bouchard, 1906
  • 14. “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
  • 15. “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.”
  • 16. “Intestinal Autointoxication” Sir William Arbuthnot Lane of Guy’s Hospital, London: performed hundreds of colectomies to rid patients of “…the cause of all the hideous sequence of maladies peculiar to civilization.”
  • 17. Constipation Is a Symptom... ...not a diagnosis • Usually need to identify cause to effect proper treatment • Definitive diagnosis often not possible in ED
  • 18. Constipation Normal Urgency Diarrhea Kyle Thompson, Wikimedia Commons
  • 19. 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
  • 20. Frequent Self-Diagnosis • Often self-diagnosed and treated • >700 OTC laxatives • Sales more than $1,000,000,000 per year in US
  • 21. Frequent Self-Diagnosis • Patients put premium on “regularity” • Concern when significant change from normal pattern
  • 22. Epidemiology • 20% of population complains of at least one episode constipation • 98% are elderly –26% of elderly men affected –34% of elderly women affected • 2,500,000 visits yearly to health care providers
  • 23. 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.
  • 24. 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
  • 25. Normal Physiology • Water passively absorbed: follows osmotic gradient produced by sodium absorption • Sodium actively absorbed: even against large concentration gradients
  • 26. 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  intraluminal pressure
  • 27. 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)
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. Most Important Factor • Diet, especially adequate fluid and fiber intake Solarnu, Flickr
  • 33. Jarlhelm, Wikimedia Commons
  • 34. Pivotal Findings: History • Thorough, detailed history: usually identifies most likely cause • Define what patient means by constipation
  • 35. 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
  • 36. Associated Symptoms • Job, sleep habits, appetite, daily activities, depression • Flatulence and bloating: consider malabsorption syndrome
  • 37. Associated Symptoms • Temperature elevation: invasive infection, inflammatory disease, prolonged fecal impaction
  • 38. Associated Symptoms Source Undetermined
  • 39. 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)
  • 40. Associated Symptoms • Abdominal pain • Location and character may localize specific disease process • Not diagnostic of constipation • May be dull, crampy, and visceral
  • 41. Associated Symptoms • Excessive gas • Anorexia • Fatigue • Headache • Low back pain • Weakness • Restlessness
  • 42. 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
  • 43. Four Ds of Constipation • Diet • Deficient fluid intake • Deficient fiber intake • Drugs
  • 44. Drugs Causing Constipation • Anticholinergics: antihistamines, tricyclic anti-depressants, phenothiazines, antiparkinsonian agents, antispasmodics • Antacids: AlOH, CaCO3 • Antihypertensives: diuretics, CCBs, clonidine
  • 45. Drugs Causing Constipation • Narcotics / opioids • Sympathomimetics: ephedrine, terbutaline • Laxative abuse • NSAIDs • Others: iron, phenytoin, barium, bismuth, sucralfate, etc.
  • 46. 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
  • 47. 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
  • 48. Physical Causes • Immobility, lack of exercise • Travel • Psychosocial stress, depression, psychosis • Failure to respond to the urge to defecate
  • 49. Diseases - Anatomic • Painful perianal lesion: fissures, hemorrhoids, abscesses, herpes • Intrinsic bowel lesions: carcinoma, diverticulitis, obstruction
  • 50. Diseases - Metabolic • Diabetes mellitus • Hypercalcemia • Hypokalemia • Porphyria
  • 51. Diseases - Endocrine • Hypothyroidism • Panhypopituitarism • Hyperparathyroidism • Pseudo-hypoparathyroidism • Pheochromocytoma • Glucagonoma
  • 52. 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
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. U.S. Air Force, Wikimedia Commons
  • 57. 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
  • 58. 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
  • 59. 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
  • 60. Rectal Exam Palpate the puborectalis for bulk, tension, tenderness National Cancer Institute, National Institutes of Health, Wikimedia Commons
  • 61. 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
  • 62. X-Rays • Plain abdominal x-ray: accurately document colonic loading –Extent of retention –Bowel obstruction –Megacolon –Volvulus –Mass lesions • Stool masses: bubbly or speckled OpenStax, Wikimedia Commons
  • 63. X-Rays Source Undetermined
  • 64. X-Rays Not all abdominal masses are stool Source Undetermined
  • 65. X-Rays Source Undetermined
  • 66. X-Rays Source Undetermined
  • 67. 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
  • 68. Chronic Constipation • Determine specific reason for this visit • Provide symptomatic relief • Refer to private physician for continued evaluation, therapy
  • 69. Morbidity and Mortality • Most bad outcomes: missed diagnosis of bowel obstruction or perforation • Be liberal with x-ray if uncertain
  • 70. 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
  • 71. Complications of Constipation Idiopathic Megacolon Source Undetermined
  • 72. Complications of Constipation Megacolon Source Undetermined
  • 73. Complications of Constipation Volvulus Source Undetermined
  • 74. Empiric Management • Eradicate underlying cause • Provide symptomatic therapy –Adequate fluid / fiber intake –If necessary: synthetic bulk agents
  • 75. 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
  • 76. 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
  • 77. Lubricants • Oral mineral oil helpful if acute painful perianal lesions • Less painful passage: soft, coated stool
  • 78. Lubricants • Usually well tolerated • Contraindicated in dysphagia: aspiration can cause lipid pneumonia
  • 79. Stool Softeners • Docusate: Colace®, Surfak® • Wetting agents, believed to enhance fecal moisture content
  • 80. Stool Softeners • As effective as placebo, no better than other methods • Can be hepato-toxic, enhance absorption of other liver toxins • No chronic use
  • 81. 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
  • 82. Osmotic Agents • Often used for colon prep for bowel procedures • In combination with activated charcoal to prevent briquettes
  • 83. Osmotic Agents • Lactulose: disaccharide formed from one molecule each of the simple sugars fructose and galactose • Metabolites draw water into bowel, causing cathartic effect through osmotic action
  • 84. Osmotic Agents • Sorbitol (AKA glucitol): slowly metabolized sugar alcohol • Draws water into large intestine  stimulates bowel movement
  • 85. Osmotic Agents • Magnesium hydroxide: Phillips' Milk of Magnesia® • Causes fluid retention, distends colon, increases peristaltic activity
  • 86. Osmotic Agents • Decreases effect of iron salts, digoxin, tetracyclines, indomethacin • Avoid in renal failure
  • 87. Osmotic Agents • Polyethylene glycol • Colonic lavage solution used as bowel prep • Effective in treating fecal impaction
  • 88. Suppositories • Especially helpful in patients with trouble expelling soft stool • Glycerine: may be soothing, help patient with constipation from painful perianal lesions
  • 89. Enemas • Tap-water or oil-retention: helpful with disimpaction • Routine use if failed outpatient laxatives • Repeated enemas damage myenteric plexus, cause motility dysfunction
  • 90. The Illinois Enema Bandit The Illinois enema bandit I heard he’s on the loose Lord, the pitiful screams Of all them college-educated women... Boy, he’d just be tyin’ ’em up (they’d be all bound down!) Just be pumpin’ every one of ’em up with all the bag fulla The Illinois enema bandit juice
  • 91. Milk and Molasses “One of the most powerful enemas that I have experienced is the "milk and molasses" enema ("M&M," for short). Use equal amounts of milk and the "blackstrap" variety of molasses (it is a strong-flavored type often used in baking).” - continued
  • 92. 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.”
  • 93. 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
  • 94. Manual Disimpaction • May be acutely necessary Source Undetermined
  • 95. Manual Disimpaction Source Undetermined Source Undetermined
  • 96. Manual Disimpaction Source Undetermined Source Undetermined
  • 97. Manual Disimpaction Source Undetermined Source Undetermined
  • 98. Manual Disimpaction Source Undetermined Source Undetermined
  • 99. Laxative Abuse 3% sodium hydroxide turns stool red, and hydrochloric acid reverses red… …demonstrates phenolphthalein, most commonly abused laxative
  • 100. 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
  • 101. Artificial Sphincter Hernan Montez, Wikimedia Commons
  • 102. 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
  • 103. 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
  • 104. Conclusions • Most important part of evaluation is the history • Most constipation can be treated by correcting the “4 Ds” – diet, deficient fluid intake, deficient fiber intake, drugs