From the Guidelines
Constipation is considered a medical emergency when it leads to severe symptoms, such as bowel obstruction, or when it is accompanied by alarm symptoms like blood in the stool or significant weight loss 1.
Key Factors for Emergency Consideration
- Severe symptoms, such as bowel obstruction
- Sudden changes in number and consistency of bowel movements
- Blood in the stool
- Significant weight loss
- Suspected impaction, especially if diarrhea accompanies constipation
Diagnostic Approach
A plain abdominal X-ray may be useful to image the extent of fecal loading and to exclude bowel obstruction 1.
Management
In patients with suspected opioid-induced constipation, a careful history should be taken to evaluate defecation patterns, dietary patterns, and symptoms of dyssynergic defecation 1.
Treatment Options
- Increase fluid intake and dietary fiber
- Exercise, if feasible
- Administer prophylactic medications, such as stool softeners and stimulant laxatives
- Consider opioid switching or changing to an equianalgesic dose of an alternative, less-constipating opioid
- Consider the use of methylnaltrexone for opioid-induced constipation, except for post-op ileus and mechanical bowel obstruction 1
Reassessment and Ongoing Care
Regular reassessment of constipation symptoms and quality of life is essential, with ongoing monitoring and adjustment of treatment as needed 1.
From the Research
Definition and Diagnosis of Constipation
- Constipation is a symptom, rather than a disease, resulting from a number of causes and disorders, including dietary factors, neurologic disorders, psychiatric disorders, colon disease, metabolic abnormalities, and medication side effects 2
- Constipation can be either a primary disorder or a secondary one, due to medications or anatomic alterations 3
Constipation as a Medical Emergency
- Constipation is considered a medical emergency when it leads to serious complications, such as fecal impaction and stercoral colitis 4
- In severe cases, constipation may cause bowel obstruction 2
- Constipation in critically ill patients is reportedly associated with poor outcomes, but a consistent definition for constipation and reports on the prognosis of critically ill patients with constipation are lacking 5
Evaluation and Management of Constipation
- The evaluation of constipation should include a thorough medical history, physical examination, and diagnostic tests to rule out underlying causes and complications 2, 3
- Management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed by intestinal secretagogues and/or prokinetic agents if necessary 3
- In the emergency department, constipation is a clinical diagnosis, and ideal management includes excluding dangerous mimics or complications and discharging the patient with a bowel regimen tailored to the likely cause of their constipation 4
Specific Cases of Constipation
- Functional constipation is a common cause of acute abdominal pain in pediatric patients, and digital rectal exploration and x-rays should be avoided in this setting, whereas an enema plays a useful diagnostic and therapeutic role 6
- Constipation in critically ill patients was not associated with in-hospital mortality based on any definition of constipation used in previous studies 5