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, 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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GEMC- The Adult Patient with Constipation- Resident Training

  1. 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. 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. 3. The Patient with Constipation Joe Lex, MD, FAAEM Temple University Hospital Philadelphia, PA
  4. 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. 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. 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. 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. 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. 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. 10. Defecation in History • Ebers Papyrus: five intestinal stimulants - figs, castor oil, seed oil, aloes, and sweet beer
  11. 11. Defecation in History • Hippocrates: “All diseases are resolved either by the mouth, the bowels, the bladder…”
  12. 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. 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. 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. 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. 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. 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. 18. Constipation Normal Urgency Diarrhea Kyle Thompson, Wikimedia Commons
  19. 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. 20. Frequent Self-Diagnosis • Often self-diagnosed and treated • >700 OTC laxatives • Sales more than $1,000,000,000 per year in US
  21. 21. Frequent Self-Diagnosis • Patients put premium on “regularity” • Concern when significant change from normal pattern
  22. 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. 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. 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. 25. Normal Physiology • Water passively absorbed: follows osmotic gradient produced by sodium absorption • Sodium actively absorbed: even against large concentration gradients
  26. 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. 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. 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. 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. 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. 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. 32. Most Important Factor • Diet, especially adequate fluid and fiber intake Solarnu, Flickr
  33. 33. Jarlhelm, Wikimedia Commons
  34. 34. Pivotal Findings: History • Thorough, detailed history: usually identifies most likely cause • Define what patient means by constipation
  35. 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. 36. Associated Symptoms • Job, sleep habits, appetite, daily activities, depression • Flatulence and bloating: consider malabsorption syndrome
  37. 37. Associated Symptoms • Temperature elevation: invasive infection, inflammatory disease, prolonged fecal impaction
  38. 38. Associated Symptoms Source Undetermined
  39. 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. 40. Associated Symptoms • Abdominal pain • Location and character may localize specific disease process • Not diagnostic of constipation • May be dull, crampy, and visceral
  41. 41. Associated Symptoms • Excessive gas • Anorexia • Fatigue • Headache • Low back pain • Weakness • Restlessness
  42. 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. 43. Four Ds of Constipation • Diet • Deficient fluid intake • Deficient fiber intake • Drugs
  44. 44. Drugs Causing Constipation • Anticholinergics: antihistamines, tricyclic anti-depressants, phenothiazines, antiparkinsonian agents, antispasmodics • Antacids: AlOH, CaCO3 • Antihypertensives: diuretics, CCBs, clonidine
  45. 45. Drugs Causing Constipation • Narcotics / opioids • Sympathomimetics: ephedrine, terbutaline • Laxative abuse • NSAIDs • Others: iron, phenytoin, barium, bismuth, sucralfate, etc.
  46. 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. 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. 48. Physical Causes • Immobility, lack of exercise • Travel • Psychosocial stress, depression, psychosis • Failure to respond to the urge to defecate
  49. 49. Diseases - Anatomic • Painful perianal lesion: fissures, hemorrhoids, abscesses, herpes • Intrinsic bowel lesions: carcinoma, diverticulitis, obstruction
  50. 50. Diseases - Metabolic • Diabetes mellitus • Hypercalcemia • Hypokalemia • Porphyria
  51. 51. Diseases - Endocrine • Hypothyroidism • Panhypopituitarism • Hyperparathyroidism • Pseudo-hypoparathyroidism • Pheochromocytoma • Glucagonoma
  52. 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. 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. 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. 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. 56. U.S. Air Force, Wikimedia Commons
  57. 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. 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. 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. 60. Rectal Exam Palpate the puborectalis for bulk, tension, tenderness National Cancer Institute, National Institutes of Health, Wikimedia Commons
  61. 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. 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. 63. X-Rays Source Undetermined
  64. 64. X-Rays Not all abdominal masses are stool Source Undetermined
  65. 65. X-Rays Source Undetermined
  66. 66. X-Rays Source Undetermined
  67. 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. 68. Chronic Constipation • Determine specific reason for this visit • Provide symptomatic relief • Refer to private physician for continued evaluation, therapy
  69. 69. Morbidity and Mortality • Most bad outcomes: missed diagnosis of bowel obstruction or perforation • Be liberal with x-ray if uncertain
  70. 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. 71. Complications of Constipation Idiopathic Megacolon Source Undetermined
  72. 72. Complications of Constipation Megacolon Source Undetermined
  73. 73. Complications of Constipation Volvulus Source Undetermined
  74. 74. Empiric Management • Eradicate underlying cause • Provide symptomatic therapy –Adequate fluid / fiber intake –If necessary: synthetic bulk agents
  75. 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. 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. 77. Lubricants • Oral mineral oil helpful if acute painful perianal lesions • Less painful passage: soft, coated stool
  78. 78. Lubricants • Usually well tolerated • Contraindicated in dysphagia: aspiration can cause lipid pneumonia
  79. 79. Stool Softeners • Docusate: Colace®, Surfak® • Wetting agents, believed to enhance fecal moisture content
  80. 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. 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. 82. Osmotic Agents • Often used for colon prep for bowel procedures • In combination with activated charcoal to prevent briquettes
  83. 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. 84. Osmotic Agents • Sorbitol (AKA glucitol): slowly metabolized sugar alcohol • Draws water into large intestine  stimulates bowel movement
  85. 85. Osmotic Agents • Magnesium hydroxide: Phillips' Milk of Magnesia® • Causes fluid retention, distends colon, increases peristaltic activity
  86. 86. Osmotic Agents • Decreases effect of iron salts, digoxin, tetracyclines, indomethacin • Avoid in renal failure
  87. 87. Osmotic Agents • Polyethylene glycol • Colonic lavage solution used as bowel prep • Effective in treating fecal impaction
  88. 88. Suppositories • Especially helpful in patients with trouble expelling soft stool • Glycerine: may be soothing, help patient with constipation from painful perianal lesions
  89. 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. 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. 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. 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. 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. 94. Manual Disimpaction • May be acutely necessary Source Undetermined
  95. 95. Manual Disimpaction Source Undetermined Source Undetermined
  96. 96. Manual Disimpaction Source Undetermined Source Undetermined
  97. 97. Manual Disimpaction Source Undetermined Source Undetermined
  98. 98. Manual Disimpaction Source Undetermined Source Undetermined
  99. 99. Laxative Abuse 3% sodium hydroxide turns stool red, and hydrochloric acid reverses red… …demonstrates phenolphthalein, most commonly abused laxative
  100. 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. 101. Artificial Sphincter Hernan Montez, Wikimedia Commons
  102. 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. 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. 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

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