Author:
Julia H.Sone
Description
Rome Criteria for the diagnosis of constipation requires 2 or more of the following for at least 3 mo:
- Straining >25% of the time
- Hard stools >25% of the time
- Incomplete evacuation >25% of the time
- 2 or fewer bowel movements per wk
Pediatric Considerations |
- 3% of pediatric outpatient visits are because of defecation disorders
- Children with cerebral palsy often develop functional constipation
- Can be classified into subgroups:
- Constipation with anatomical origins (anal stenosis/strictures, ectopic anus, imperforate anus, sacrococcygeal teratomas)
- Colonic neuromuscular disease (Hirschsprung disease)
- Defecation disorders (functional constipation and nonretentive fecal soiling)
- Functional fecal retention
- Most common cause of fecal retention and soiling in children is functional fecal retention:
- Caused by fears associated with defecation
- Associated with irritability, abdominal cramps, decreased appetite, early satiety
|
Etiology
- Metabolic and endocrine:
- Diabetes
- Uremia
- Porphyria
- Hypothyroidism
- Hypokalemia (severe)
- Hypomagnesium (severe)
- Hypercalcemia
- Pheochromocytoma
- Panhypopituitarism
- Pregnancy
- Functional and idiopathic:
- Colonic irritable bowel syndrome
- Diverticular disease
- Colonic inertia
- Megacolon/megarectum
- Pelvic intussusception
- Nonrelaxing puborectalis
- Rectocele/sigmoidocele
- Posthysterectomy syndrome
- Descending perineum
- Pharmacologic:
- Analgesics
- Anesthetics
- Antacids
- Anticholinergics
- Anticonvulsants
- Antidepressants
- Antiemetics (ondansetron)
- Antihistamines
- Antihypertensives
- Calcium channel blockers
- Diuretics
- Ferrous compounds
- Laxative abuse
- MAOIs
- Opiates
- Paralytic agents
- Parasympatholytics
- Phenothiazines
- Psychotropics
- Neurologic:
- Central Parkinson disease
- Multiple sclerosis
- Cerebrovascular accidents
- Spinal cord lesions/injury
- Peripheral Hirschsprung disease
- Chagas disease
- Neurofibromatosis
- Autonomic neuropathy
- Mechanical obstruction:
- Neoplasm
- Stricture of colon, rectum, or anus
- Hernia
- Volvulus
- Intestinal pseudo-obstruction
Signs and Symptoms
- Constipation is a symptom, not a disease
- Passage of hard stool
- Straining/difficulty passing stool
- Infrequent bowel movements
- Abdominal distention/bloating
- Firm/hard stool on digital rectal exam:
- May have empty rectal vault
- Diarrhea (liquid stool passes around firm feces)
History
- Age of onset of symptoms
- Diet and exercise regimen
- Stool size, caliber, consistency, frequency, ease of defecation
- Medical and surgical history:
- Medications that can slow colonic transit like β-blockers, high-dose calcium channel blockers, narcotics
- Use of enemas, laxatives, and digital manipulation to facilitate defecation
- Associated pelvic floor dysfunction:
- Urinary symptoms
- Rectocele
Physical Exam
- Abdominal exam may reveal a mass due to stool
- Rectal exam to assess for outlet obstruction:
- Ability to squeeze and relax the sphincter
- Is there a rectocele or cystocele?
- Assess firmness of stool
Essential Workup
Thorough history and physical exam:
- Medical, surgical, and psychiatric investigation and date of onset
- Note abdominal distention, hernias, tenderness, or masses
- Complete anorectal exam for anal stenosis, fissure, neoplasm, sphincter tone, perineal descent, tenderness, spasm
Diagnostic Tests & Interpretation
Lab
- Only necessary when considering metabolic/endocrine disorders
- CBC if inflammatory or neoplastic origin
- Electrolytes and calcium indicated if at risk of:
- Thyroid function test if patient appears to be hypothyroid
Imaging
- Rarely indicated unless an underlying process suspected
- Abdominal radiograph:
- Large amount of feces in colon
- Dilated colon that needs decompression
- CT scan of abdomen/pelvis to r/o perforation in elderly, constipated patient with abdominal pain/fever
- Barium/gastrografin enema study:
- Diverticulosis
- Megarectum
- Megacolon
- Hirschsprung disease
- Stricture from inflammation or tumor
Differential Diagnosis
Prehospital
Establish IV access for patients with significant abdominal pain
Initial Stabilization/Therapy
IV fluids for dehydrated/hypotensive patients
ED Treatment/Procedures
- Clean out colon:
- Enemas, suppositories
- Manual disimpaction of hard stool
- Laxatives
- Maintain bowel regimen:
- Increase noncaffeinated fluids (8-10 cups/d)
- Increase dietary fiber intake (20 g/d)
- Stool softeners
- Exercise
- Change medications causing constipation
Medication
- Enemas:
- Fleet: 120 mL (peds: 5-11 yr old: 60-120 mL) per rectum (PR)
- Mineral oil: 60-150 mL (peds: 5-11 yr old, 30-60 mL; older than 12 yr, 60-150 mL) PR daily
- Tap water: 100-500 mL PR
- Fiber supplements:
- Methylcellulose: up to 6 g daily in 0.45-3 g divided doses
- Psyllium: Up to 30 g daily in divided 2.5-7.5 g doses (peds: 6-11 up to 15 g daily in divided 2.5-3.75 g doses)
- Calcium polycarbophil: 1,250 mg 1-4 times/d (peds: 6-12 yr, 625 mg 1-4 times/d; older than 12 yr, 1,250 mg 1-4 times/d)
- Wheat dextrin: 4 g mixed in 1 cup water t.i.d (peds: 6-12 yr, 2 g mixed in 1 cup water t.i.d; older than 12 yr: 4 g in cup water t.i.d)
- Laxatives (osmotic):
- Lactulose: 15-30 mL (peds: 1 mL/kg) PO daily to b.i.d
- Polyethylene glycol: 17 g (peds: 0.8 g/kg/d dissolved in 4-8 oz of liquid) PO daily dissolved in liquid
- Milk of magnesia: 2,400-4,800 mg Mg hydroxide PO (peds: 6 mo-1 yr: 40 mg/kg Mg hydroxide; 2-5 yr: 400-1,200 mg Mg hydroxide; 6-11 yr: 1,200-2,400 mg Mg hydroxide; over 12 yr: 2,400-4,800 mg Mg hydroxide) per day or divided b.i.d-q.i.d prn
- Laxatives (stimulant):
- Bisacodyl: 10-15 mg PO daily (peds: <3 yr, 5 mg PR daily; 3-12 yr, 5-10 mg PO/PR daily; >12 yr, 5-15 mg PO daily or 10 mg PR daily)
- Senna: 0.5-2 g daily (peds: 2-6 yr 0.15-0.6 g; 6-12 yr 0.25-1 g daily)
- Stool softeners:
- Docusate sodium: 100 mg (peds: 3-5 mg/kg/d in div doses) PO daily to b.i.d
- Mineral oil: 15-45 mL (peds: 5-15 mL) PO daily
- Suppositories:
- Glycerin: 2-3 g (peds: 2-6 yr 1-1.2 g; >6 yr 2 g) PR PRN
Disposition
Admission Criteria
- Patients with severe abdominal pain, nausea, and emesis
- Neurologically impaired, elderly, morbidly obese who cannot be cleaned out in the ED or home
- Bowel obstruction/peritonitis
Discharge Criteria
- No comorbid illness requiring admission
- Pain free
- Adequately cleaned out
Issues for Referral
GI follow-up for further evaluation and treatment
Follow-up Recommendations
Primary care or GI follow-up for patients with longstand ing constipation
- DoodyDP, FloresA, RodriguezLA. Evaluation and management of intractable constipation in children . Semin Colon Rectal Surg. 2006;17(1):29-37.
- FordAC, TalleyNJ. Laxatives for chronic constipation in adults . BMJ. 2012;345:e6168.
- LeungL, RiuttaT, KotechaJ, et al. Chronic constipation: An evidence-based review . J Amer Board of Fam Med. 2011;24(4):436-451.
- TalleyN. Differentiating functional constipation from constipation-predominant irritable bowel syndrome: Management implications . Rev Gastroenterol Disord. 2005;5(1):1-9.
- WaldA. Constipation: advances in diagnosis and treatment . JAMA. 2016;315(2):185-191.
- WexnerSD, PembertonJH, BeckDE, et al., eds. The ASCRS Textbook of Colon and Rectal Surgery. Springer; 2007.
See Also (Topic, Algorithm, Electronic Media Element)