PANCE Blueprint GI and Nutrition (9%)

Constipation (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Constipation

Patient will present as → a 65-year-old male with chronic low back pain complaining of bloating, abdominal pain, straining and pain with bowel movements. He reports less than 3 bowel movements per week that are very hard and difficult to pass.  The patient is on 50 mcg of transdermal Fentanyl and takes four 10 mg Norco per day for breakthrough pain.

Definition of constipation

  • According to the Rome III criteria, functional constipation is defined as any two of the following features:
    • straining
    • lumpy hard stools
    • a sensation of incomplete evacuation
    • use of digital maneuvers
    • a sensation of anorectal obstruction or blockage with 25 percent of bowel movements
    • a decrease in stool frequency (less than three bowel movements per week)

The above criteria must be fulfilled for the last three months with symptom onset six months prior to diagnosis, loose stools should rarely be present without the use of laxatives, and there must be insufficient criteria for a diagnosis of irritable bowel syndrome.

  • Patients who are older than 50 with new onset constipation should be evaluated for colon cancer
  • Bloating, abdominal pain, straining and pain with bowel movements
  • Opiate use is a classic cause of constipation. All patients on chronic opioids should be prophylaxed with a stool softener
  • Think of causes of secondary causes of constipation: DM, hypothyroidism, MS, dehydration, medications are common

Physical examination — A comprehensive physical examination should be performed that includes a rectal exam to palpate for hard stool, assess for masses, anal fissures, hemorrhoids, sphincter tone, push effort during attempted defecation, prostatic hypertrophy in males, and posterior vaginal masses in females.

  • Imaging — There are limited data to support the role of imaging in the evaluation of constipation in the older adult
  • Laboratory testing: CBC, CMP, TSH to identify secondary causes

Increase fiber (20-25 grams per day), exercise and water in diet

  • The effects of fiber on bowel movements may take several weeks
  • In a small study of healthy volunteers, the consumption of extra fluid was not associated with an increase in stool output

Laxatives:  Laxative usage in older adults should be individualized based on the patient's history, comorbidities, drug interactions, and side effects.

  • Bulk-forming laxatives first line — Bulk-forming laxatives include psyllium seed (eg, Metamucil), methylcellulose (eg, Citrucel), calcium polycarbophil (eg, FiberCon®), and wheat dextrin (eg, Benefiber)
  • Osmotic laxatives can be used in patients not responding satisfactorily to bulking agents. Start with low-dose polyethylene glycol (PEG) as it has been demonstrated to be efficacious and well tolerated in older adults.
  • Stimulant laxatives — Stimulant laxatives affect electrolyte transport across the intestinal mucosa and enhance colonic transport and motility.
  • Stool softeners, suppositories (glycerin or bisacodyl), and enemas have limited clinical efficacy and should only be used in specific clinical scenarios.
  • A patient with constipation lasting for more than 2 weeks that is refractory to treatments should undergo further investigation to identify underlying cause
Question 1
A 70 year old woman presents with 14-month history of constipation. The workup was negative. What management option would you recommend for her?
A
Daily laxative
Hint:
See C for explanation
B
Regular enema
Hint:
See C for explanation
C
Increased fluid intake and high-fiber diet
D
Daily glycerin suppository
Hint:
See C for explanation
Question 1 Explanation: 
Constipation with no underlying etiology should be treated conservatively - Increased fluid intake and high-fiber diet. All other options may not be necessary.
Question 2
Functional constipation is difficulty passing stools for reasons other than organic causes. Which of the following is not a component of Rome III diagnostic criteria for functional constipation?
A
Straining
B
Sensation of incomplete evacuation
C
Lumpy or hard stools
D
> 3 bowel movements per week
Question 2 Explanation: 
According to Rome III criteria for functional constipation, a patient must have experienced at least 2 of the following symptoms over the preceding 3 months: - Straining - Sensation of incomplete evacuation - Lumpy or hard stools - <3 bowel movements per week - Sensation of anorectal obstruction - Manual maneuvering required to defecate.
Question 3
Which of the following medications does not cause constipation
A
Opioids
Hint:
See answer C for explanation
B
Calcium channel blockers
Hint:
See answer C for explanation
C
Beta-blockers
D
NSAIDs
Hint:
See answer C for explanation
Question 3 Explanation: 
Beta-blockers do not cause constipation. All of the other medications do.
Question 4
Which of the following is not a pharmacological agent used in treating constipation
A
Loperamide
B
Docusate sodium
Hint:
Is a stool softener. It allows incorporation of water and fat into stools, causing stools to soften. It’s indicated for patients who should avoid straining during defecation.
C
Lactulose
Hint:
Is an osmotic laxative. It produces an osmotic effect in the colon resulting in bowel distention and stimulation of peristalsis.
D
Senna
Hint:
Is a stimulant laxative. It induces defecation by acting directly on the intestinal mucosa or nerve plexus, which stimulates peristaltic activity.
Question 4 Explanation: 
Loperamide is an antidiarrheal agent.
Question 5
Which of the following is the most common organic cause of constipation in children?
A
Parkinson’s disease
Hint:
See answer C for explanation
B
Colon cancer
Hint:
See answer C for explanation
C
Hirschsprung disease
D
Diverticular disease
Hint:
See answer C for explanation
Question 5 Explanation: 
Hirschsprung disease is the most common organic cause of constipation in children. It is a congenital anomaly of innervation of the lower intestine, usually limited to the colon, resulting in partial or total functional obstruction. Symptoms are obstipation and distention. Diagnosis is by barium enema and rectal biopsy. All others occur in adulthood.
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