inpatient / gastroenterology


Last Updated: 1/6/2023

# Constipation

-- Chart Check: *** constipating meds, h/o abdominal surgeries
-- HPI Intake: *** last BM, # BM per week, character of stool, meds (opioids, anticholinergics, ondansetron), red flags (sudden change >50yo, blood, tenesmus, weight loss, FHx CRC)
-- Can't Miss: *** peritonitis, obstruction
-- Admission Orders: ***
-- Initial Treatment to Consider: ***

-- Last BM: ***
-- BM Per Week: ***
-- Stool Character: ***
-- Straining: ***
-- Incomplete Evacuation: ***
-- Constipating Medications:
*** opioids, anticholinergics, ondansetron
-- Red Flag Sxs:
*** sudden change >50yo, blood, tenesmus, weight loss, FHx CRC

-- History: *** last BM, # BM per week, character of stool, meds (opioids, anticholinergics, ondansetron), red flags (sudden change >50yo, blood, tenesmus, weight loss, FHx CRC)
-- Clinical/Exam: *** abdominal pain, distention, signs of peritonitis, jaundice, DRE (fissure, hemorrhoids, tone)
-- Data: ***
-- Etiology: *** adynamic, obstruction, meds (opioids, anticholinergic, ondansetron), functional, metabolic (hyperCa, hypoMag, hypothyroid)

Constipation DDx
Functional: slow transit/pelvic floor/IBS
-- Obstruction: cancer/stricture, volvulus
-- Adynamic: severe illness, Ogilvie’s, gallstone, post-surgery opiates
-- Metabolic: diabetes, hypothyroid, hypercalcemia and hyperPTH
-- Meds: opiate, anticholinergic, iron, CCB, BB, ondansetron
-- Neurogenic: Parkinson’s, Hirschsprung, Chagas, MS, spinal cord injury

-- CBC, BMP, Mg, TSH
-- KUB or CTAP if c/f obstruction
-- Colonoscopy when able if red flags, c/f underlying cancer or IBD

-- Lifestyle: *** fiber (broccoli, berries, lentils, beabs, whole grain, almonds), hydration, exercise, biofeedback, pelvic floor PT
-- Medications: *** Senna and Miralax → lactulose, mag citrate → suppository → enema → disimpaction
-- Ppx if >60yo, prolonged immobility, poor fluid intake, preexisting constipation, meds
-- Limit the use of opioids, anticholinergics, iron, ondansetron, diuretics

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If You Remember Nothing Else

In general for hospitalized patients with constipation, start with senna standing and miralax PRN. Elderly patients may do better with miralax monotherapy. Next trial lactulose, then suppositories, then enemas, then manual disimpaction. Avoid Maalox, milk of magnesia, mag citrate, and fleets enemas in patients with ESRD. Avoid DRE or suppositories/enemas in patients who are neutropenic.

Clinical Pearls

  • Docusate sodium (Colace) has no evidence in hospitalized patients; 2 senna qhs > senna and colace
  • If risk factors for hospital constipation, add senna standing and miralax PRN; if on opioids, make the miralax standing
  • Functional constipation can evaluated using Rome IV Criteria (straining, lumpy or hard stools, sesation of incomplete evacuation, sensation of blockage, manual maneuvers to facilitate defecation, <3 spontaneous BMs per week; should consider other etiologies if any of the following: GI bleeding, IDA, weight loss, palpable adbominal mass or lymphadenopathy, FHx of colon cancer and patient without age-appropriate cancer screening, onset of symptoms age >50 without colo screen, sudden or acute onset f new changes in bowel habits
  • Avoid any rectal procedures (inlcuding DRE) in neutropenic patients
  • Avoid Mg and Phos products if ESRD (ex: Maalox, milk of magnesia, mag citrate, fleets enema has Phos)
  • High-fiber foods include vegetables (e.g., broccoli, peas), fruits (e.g. berries, apples, avocado), legumes (e.g., lentils, black beans), grains (e.g. oatmeal, whole grain bread), and nuts/seeds (almonds, chia seeds)
  • If constipation gets worse with fiber supplementation, could indicate an underlying slow transit constipation or defecatory disorder
  • In general laxatives should be taken for short courses to avoid dependency
  • Fecal impaction is common in older adults and can manifest with paridoxical diarrhea which is seepage of fece around the site of impaction
  • Rectal lactulose can be deliver for patients with hepatic encephalopathy unable to take PO
  • Saline or Fleet enemas (sodium phosphate) attempt to break up the stool whereas mineral oil enemas theoretically work via lubrication
  • Acute colonic pseudo-obstruction (Ogilvie’s Syndrome) is global dilation of bowels leading to increased risk of perforation - treated with neostigmine, though rarely since at many institutions this needs to be given in an ICU setting
  • Senna and bisacodyl an cause melanosis coli which is a benign hyperpigmentation of colonic epithelial cells seen on colonoscopy

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