What is the appropriate management for a 67‑year‑old man with two‑day obstipation, wheezing, and bilateral lower‑leg edema?

Management of a 67-Year-Old Man with Obstipation, Wheezing, and Bipedal Edema

This patient requires immediate assessment for fecal impaction with digital rectal examination and abdominal imaging, followed by aggressive disimpaction if confirmed, while simultaneously addressing the cardiac and respiratory manifestations that suggest heart failure as the underlying cause of his multi-system presentation.

Immediate Clinical Assessment

Rule Out Fecal Impaction First

• Perform digital rectal examination immediately to assess for impaction, as this is the most likely cause of 2-day obstipation in an elderly patient with comorbidities 1
• Obtain abdominal radiograph to rule out mechanical obstruction and confirm impaction 2
• Critical pitfall: Diarrhea accompanying constipation suggests overflow around impaction—do not treat the diarrhea without first ruling out impaction 2

Assess Cardiopulmonary Status

• The combination of bipedal edema and wheezing strongly suggests cardiac decompensation with pulmonary congestion 3
• Measure oxygen saturation and apply supplemental oxygen immediately if SpO2 <90% to prevent hypoxic complications 3
• Obtain chest radiograph to evaluate for pulmonary edema, which presents with dyspnea and bilateral alveolar opacities 2

Management of Obstipation

If Impaction is Confirmed

• Administer glycerine suppository followed by mineral oil retention enema 2
• Perform manual disimpaction after pre-medication with analgesic ± anxiolytic to reduce discomfort 2
• Critical warning: Avoid vigorous rectal manipulation in this patient with cardiac compromise, as vagal stimulation can cause bradycardia and hypotension, potentially precipitating acute pulmonary edema 4

Post-Disimpaction Management

• Initiate bisacodyl 10-15 mg daily with goal of 1 non-forced bowel movement every 1-2 days 2
• Add stool softener (senna ± docusate, 2-3 tablets BID-TID) 2
• If constipation persists, consider adding polyethylene glycol, lactulose 30-60 mL BID-QID, or magnesium hydroxide 30-60 mL daily 2
• Consider metoclopramide 10-20 mg PO QID as a prokinetic agent if gastroparesis is suspected 2

If No Impaction is Found

• Rule out other treatable causes: hypercalcemia, hypokalemia, hypothyroidism, diabetes mellitus 2
• Review and discontinue any non-essential constipating medications (anticholinergics, opioids, antacids) 2
• Increase fluid intake and encourage physical activity if appropriate 2

Management of Cardiopulmonary Manifestations

Immediate Respiratory Support

• Apply continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation if respiratory rate >25 breaths/min or SpO2 <90% despite conventional oxygen 3
• Target SpO2 >90% with supplemental oxygen via face mask or non-rebreather 3

Cardiac Management

• Do NOT use beta-blockers for wheezing in this patient with frank cardiac failure evidenced by pulmonary congestion and edema, as this can precipitate cardiovascular collapse 3
• Consider diuretics for fluid overload, but monitor carefully to avoid excessive preload reduction which can compromise cardiac output 4
• Target 25-30% blood pressure reduction initially if hypertensive—avoid excessive rapid reduction as it compromises organ perfusion 3

Bronchodilator Therapy

• Treat wheezing with bronchodilators appropriate for cardiac patients (avoid beta-agonists if possible due to cardiac effects) 2
• Consider ipratropium bromide as a safer alternative in patients with cardiac disease 2

Critical Pitfalls to Avoid

1. Never treat apparent diarrhea without ruling out overflow incontinence from impaction 2
2. Avoid aggressive straining during defecation, as this increases intrathoracic pressure and can precipitate acute pulmonary edema in patients with borderline cardiac function 4
3. Do not use beta-blockers for wheezing in patients with pulmonary congestion or low-output cardiac state 3
4. Avoid excessive diuresis that could compromise cardiac output through inadequate preload 4
5. Monitor for iatrogenic cardiogenic shock from overly aggressive use of vasodilators and diuretics 3

Follow-Up and Prevention

• Reassess within 48 hours to ensure adequate response to constipation treatment 2
• Establish prophylactic bowel regimen with stimulant laxative to prevent recurrence 2
• Optimize cardiac management to prevent recurrent decompensation 3
• Address underlying causes: review medications, optimize fluid status, and treat any identified cardiac pathology 2