Sample GI Referral Letter
Patient Information
Patient: 44-year-old female
Reason for Referral: Refractory chronic constipation requiring specialized evaluation and management
Clinical Summary
Chief Complaint:
Severe chronic constipation with bowel movements occurring only once every two weeks, characterized by thin stools.
Recent History:
- Emergency department visit with CT abdomen/pelvis demonstrating colon distended with stool throughout 1
- Reports significant straining and sensation of incomplete evacuation 1
- Bowel movement frequency: approximately once every 14 days with thin-caliber stools 1
Failed Therapeutic Trials:
- Stool softeners (docusate): No improvement 2
- Polyethylene glycol 3350 (Miralax): Failed at standard dosing of 17g daily 3
- Enemas: Provided only temporary relief 4
- Over-the-counter stimulant laxatives: Inadequate response 1
Physical Examination Findings
- Digital rectal examination performed: [Please document findings regarding resting sphincter tone, puborectalis contraction during squeeze, ability to expel examining finger during simulated defecation, presence of rectocele, and perineal descent] 1
- Abdominal examination: [Document presence/absence of distension, tenderness, palpable stool] 4
Diagnostic Workup Completed
- CT abdomen/pelvis (ED visit): Colon filled with stool, no mechanical obstruction identified 1
- Complete blood count: [Insert results] 1
- Metabolic panel including TSH, calcium, glucose: [Insert results if obtained] 1
- Colonoscopy status: [Document if patient >50 years or has alarm symptoms; if not performed, note indication for GI to consider] 1
Clinical Assessment
This patient meets criteria for refractory chronic constipation requiring specialized gastroenterology evaluation. Based on the clinical presentation with infrequent bowel movements (once every two weeks), thin stools, CT evidence of severe fecal loading, and failure of multiple over-the-counter therapies, she likely has either slow-transit constipation, a defecatory disorder (pelvic floor dysfunction), or a combination of both 1, 5.
The thin stool caliber and severe fecal retention despite laxative use raise concern for possible outlet obstruction from pelvic floor dysfunction, which would require anorectal manometry and balloon expulsion testing for definitive diagnosis 1, 5. A normal digital rectal examination does not exclude defecatory disorders 1.
Specific Questions for Gastroenterology
Anorectal physiologic testing: Does this patient require anorectal manometry and balloon expulsion test to evaluate for dyssynergic defecation or pelvic floor dysfunction? 1, 5
Colonic transit study: Should colonic transit testing be performed to differentiate slow-transit constipation from outlet obstruction? 1, 5
Advanced pharmacotherapy: Is this patient a candidate for prescription secretagogues (lubiprostone 24 mcg twice daily, linaclotide 145-290 mcg daily) or prokinetic agents (prucalopride 1-2 mg daily) given failure of osmotic and stimulant laxatives? 4, 6, 7
Biofeedback therapy: If defecatory disorder is confirmed, would the patient benefit from pelvic floor biofeedback therapy? 1, 5
Structural evaluation: Does the patient require colonoscopy if not previously performed (patient is 44 years old with new-onset severe constipation and thin stools)? 1
Defecography: Should MR or fluoroscopic defecography be considered to evaluate for structural abnormalities such as rectocele, rectal prolapse, or intussusception? 1
Current Medications
[List all current medications, particularly noting any with constipating effects such as anticholinergics, opioids, calcium channel blockers, iron supplements] 1, 4
Urgency
Routine referral - Patient is stable but experiencing significant quality of life impairment from refractory constipation requiring specialized diagnostic evaluation and management 8.
Thank you for your expertise in evaluating and managing this complex case of refractory constipation.
Sincerely,
[Your Name]
[Contact Information]