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1. Project: Ghana Emergency Medicine Collaborative
Document Title: The Adult Patient With Constipation
Author(s): Joe Lex, MD, FACEP, FAAEM, (Temple University) 2013
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3. The Patient
with
Constipation
Joe Lex, MD, FAAEM
Temple University Hospital
Philadelphia, PA

4. Objectives
• Define constipation as determined
by the AGA
• Describe the physiology of normal
defecation
• List factors from the history which
provides clues to the seriousness
of its cause

5. Objectives
• Describe the 4 Ds and 3 Hs of
chronic constipation
• Explain potential severe
complications of constipation
• List the mechanism of action and
effectiveness for several
treatments for constipation

6. Some Definitions
Constipation: from Latin constipatio -
a crowding together
Obstipation: from Latin obstipatio - a
close pressure
Dyschezia: from Greek chezo - to
defecate
Aperient: from Latin aperiens - to
bring forth, produce

7. Some Definitions
Cathartic: from Greek - to cleanse
Purgative: from Latin purgativus -
remove by cleansing
Laxative: from Latin laxativus -
mitigating, assuaging
Physic: from Latin physica, physice -
to produce, grow

8. Some Definitions
Epsom Salts: sulphate of magnesia
having cathartic qualities;
originally prepared by boiling down
the mineral waters at Epsom,
England (home of racetrack)

9. Defecation in History
• Old Testament Jews could not
face or aim buttocks at Jerusalem
• Essenes could not dig on the
Sabbath, so did not defecate
• Muslims cannot face Mecca or turn
back on it, but cannot face sun or
moon

10. Defecation in History
• Ebers Papyrus: five intestinal
stimulants - figs, castor oil, seed
oil, aloes, and sweet beer

11. Defecation in History
• Hippocrates: “All diseases are
resolved either by the mouth, the
bowels, the bladder…”

12. John Harvey Kellogg, MD
From Battle Creek Michigan:
“One daily evacuation is chronic
constipation.”
“Who has not seen a prodigious
evacuation of the bowels at the
hands of a physician terminate a
case of insanity?”
Brother Will made breakfast foods...

13. “Intestinal Autointoxication”
Definition: self-poisoning from from
one’s own retained waste
(The constipated person) “…is
always working toward his own
destruction; he makes continual
attempts at suicide by
intoxication.”
- Charles Bouchard, 1906

14. “Intestinal Autointoxication”
Books published between 1900 and
1920 include...
The Conquest of Constipation
The Lazy Colon
Le Colon Homicide
Intestinal Management for Longer,
Happier Life

15. “Intestinal Autointoxication”
“…a burden, fermenting,
decomposing, putrefying, filling the
body with poisonous substances...
…sewer-like blood…
…the cause of ninety percent of
disease...
…constipation shortens life.”

16. “Intestinal Autointoxication”
Sir William Arbuthnot Lane of Guy’s
Hospital, London: performed
hundreds of colectomies to rid
patients of “…the cause of all the
hideous sequence of maladies
peculiar to civilization.”

17. Constipation Is a Symptom...
...not a diagnosis
• Usually need to identify cause to
effect proper treatment
• Definitive diagnosis often not
possible in ED

18. Constipation
Normal
Urgency
Diarrhea
Kyle Thompson, Wikimedia Commons

19. Definition: Any Two of Four
• Straining to pass stool 25% of time
• Lumpy or hard stools 25% of time
• Incomplete sensation of
evacuation 25% of time
• Two or fewer stools per week
- American Gastroenterological Association

20. Frequent Self-Diagnosis
• Often self-diagnosed and treated
• >700 OTC laxatives
• Sales more than $1,000,000,000
per year in US

21. Frequent Self-Diagnosis
• Patients put premium on
“regularity”
• Concern when significant change
from normal pattern

22. Epidemiology
• 20% of population complains of at
least one episode constipation
• 98% are elderly
–26% of elderly men affected
–34% of elderly women affected
• 2,500,000 visits yearly to health
care providers

23. Epidemiology
• Laxatives used on regular basis by
–30% of general population
–60% of all elderly individuals,
–75% of nursing home elderly
• Multifactorial: low dietary fiber,
sedentary habits, medicines,
neurologic diseases, decreased
thirst, etc.

24. Normal Physiology
• GI tract gets 9 to 10 liters per day
of secretions and ingested fluids
• Small intestine absorbs all but 500
to 600 ml
• Colon absorbs more
• About 100 ml/day of fluid lost in
the stool

25. Normal Physiology
• Water passively absorbed: follows
osmotic gradient produced by
sodium absorption
• Sodium actively absorbed: even
against large concentration
gradients

26. Normal Defecation
Rectum distends  internal sphincter
relaxes  external sphincter contracts
 puborectalis muscle relaxes with
Valsalva  pelvic floor ascends 
anorectal angle straightens  anal
canal opens  straining 
intraluminal pressure

27. Normal Defecation
• Constant pressure on rectum /
anal sphincter: 20 mmHg
• Normal defecation: 40 mmHg for 5
to 6 seconds
• Constipation and breath hold /
strain : 200 mmHg for 10 to 15
seconds (Valsalva)

28. Normal Defecation
• South American Indians, Africans:
diet of fruits, vegetables, grains
• Average American: meat, sugar,
white flour
• Stool bulk of former 3 to 5 times
that of latter

29. Abnormal Defecation
Motility imbalance between…
...churning nonpropulsive forces that
regulate constipation and fluid
absorption and
...propulsive forces that propel the
feces toward the rectum
• Normals: intestinal transit time and
bowel frequency age independent

30. Abnormal Defecation
Elderly patients with idiopathic
chronic constipation have...
...prolonged total gut transit times
(colonic inertia)
...decreased rectal sensitivity
...increased colonic absorption of
fluids from fecal material
...hard stools

31. Abnormal Defecation
• Ignoring urge to defecate due to
inconvenience, incapacity, or
painful anorectal lesions
• Resisting urge to defecate
suppresses normal sensory stimuli
evoked by rectal distention,
leading to chronic rectal distention
and decreased motor tone

32. Most Important Factor
• Diet, especially
adequate fluid
and fiber intake
Solarnu, Flickr

33. Jarlhelm, Wikimedia Commons

34. Pivotal Findings: History
• Thorough, detailed history:
usually identifies most likely
cause
• Define what patient means by
constipation

35. Pivotal Findings: History
• Character of stools: provide clue to
diagnosis, suggest seriousness
–Diarrhea alternating with
constipation: suggests obstructing
colonic mass lesion, irritable bowel
• Changes in diet and exercise
• New medications

36. Associated Symptoms
• Job, sleep habits, appetite, daily
activities, depression
• Flatulence and bloating: consider
malabsorption syndrome

37. Associated Symptoms
• Temperature elevation: invasive
infection, inflammatory disease,
prolonged fecal impaction

38. Associated Symptoms
Source Undetermined

39. Associated Symptoms
• Nausea and vomiting: nonspecific
–If present think acute obstruction
• Weakness: dehydration,
electrolyte imbalance
• Weight loss, decreased appetite:
debilitating diseases (e.g., cancer,
inflammatory bowel)

40. Associated Symptoms
• Abdominal pain
• Location and character may
localize specific disease process
• Not diagnostic of constipation
• May be dull, crampy, and visceral

41. Associated Symptoms
• Excessive gas
• Anorexia
• Fatigue
• Headache
• Low back pain
• Weakness
• Restlessness

42. Associated Symptoms
• Fecal impaction: may present with
low-grade fever, fecal
incontinence, alternating diarrhea
and constipation
• Most concerning symptoms: rectal
bleeding, change in stool caliber
–Suggest possible colorectal cancer

43. Four Ds of Constipation
• Diet
• Deficient fluid intake
• Deficient fiber intake
• Drugs

44. Drugs Causing Constipation
• Anticholinergics: antihistamines,
tricyclic anti-depressants,
phenothiazines, antiparkinsonian
agents, antispasmodics
• Antacids: AlOH, CaCO3
• Antihypertensives: diuretics,
CCBs, clonidine

45. Drugs Causing Constipation
• Narcotics / opioids
• Sympathomimetics: ephedrine,
terbutaline
• Laxative abuse
• NSAIDs
• Others: iron, phenytoin, barium,
bismuth, sucralfate, etc.

46. Herbals and “Alternatives”
• Variety of herbal laxatives at
health food stores
• Vegetable products containing
anthraquinones: aloe, senna,
cascara
• Work acutely: chronic efficacy and
safety less certain
–Melanosis coli: benign complication

47. Herbals and “Alternatives”
• High colonic: high-volume enemas
from alternative practitioners
• Some enemas contain unusual
salts: attempt to influence the
function of other organs
• Questionable hygiene: intestinal
parasite outbreaks reported

48. Physical Causes
• Immobility, lack of exercise
• Travel
• Psychosocial stress, depression,
psychosis
• Failure to respond to the urge to
defecate

49. Diseases - Anatomic
• Painful perianal lesion: fissures,
hemorrhoids, abscesses, herpes
• Intrinsic bowel lesions: carcinoma,
diverticulitis, obstruction

50. Diseases - Metabolic
• Diabetes mellitus
• Hypercalcemia
• Hypokalemia
• Porphyria

51. Diseases - Endocrine
• Hypothyroidism
• Panhypopituitarism
• Hyperparathyroidism
• Pseudo-hypoparathyroidism
• Pheochromocytoma
• Glucagonoma

52. Diseases - Neurologic
Central
• Cord lesions
• Cauda equina
• Lumbar disc
disease
• Tabes dorsalis
• Multiple sclerosis
• Parkinsonism
• Stroke
• Brain tumor
Peripheral
• Autonomic
neuropathy
• Diabetes mellitus
• Amyloidosis
• Paraneoplastic
disease
• Chagas' disease
• Neurofibromatosis
• Hirschsprung's

53. Idiopathic Constipation
Slow transit
• Failure of propulsion through colon
• Primary symptom: infrequent stool
–Once stool in position for evacuation,
expelled relatively easily
• Most common mechanism of
idiopathic constipation

54. Idiopathic Constipation
Functional outlet obstruction
• Ineffective opening or blockage of
anal canal, or failure of expulsion
• Normal defecation: barriers to
stool evacuation removed
• Normal stool frequency but
difficulty with evacuation

55. Three Hs: Chronic Constipation
• Hypertonic: diverticulosis, irritable
bowel syndrome
• Hypotonic: neurogenic, dementia /
stroke, diabetic neuropathy, MS,
ALS, cord lesion, psychogenic,
debilitation, Parkinsonism
• Habit: toilet training

56. U.S. Air Force, Wikimedia Commons

57. General Physical Exam
• Evaluate for systemic diseases
• Search for organic causes
• Abdomen: usually normal
–May show tenderness, mass,
distention, evidence of obstruction
• Perineum: fissure, inflamed
hemorrhoid, perirectal abscess

58. Rectal Exam - Most Important!
• Squeezing to prevent defecation
assesses anal sphincter tone
• Bearing down to simulate
defecation relaxes anal sphincter,
puborectalis
–Paradoxical contraction of either
suggests outlet obstruction

59. Rectal Exam - Most Important!
• Feel for stricture, tumor, mass
• Usually feel large amounts of hard
stool in rectum
–Empty ampulla: obstructive disease
or hypertonic constipation
–Soft, putty-like stools: hypotonic or
habit constipation

60. Rectal Exam
Palpate the
puborectalis
for bulk,
tension,
tenderness
National Cancer Institute, National Institutes of Health,
Wikimedia Commons

61. Rectal Exam - Most Important!
• Results may not correlate with
complaint of constipation or with
abdominal radiographs
• Rectal exam alone cannot confirm
or exclude constipation
• Check stool for occult blood: colon
carcinoma vs. strain at stool

62. X-Rays
• Plain abdominal x-ray: accurately
document colonic loading
–Extent of retention
–Bowel obstruction
–Megacolon
–Volvulus
–Mass lesions
• Stool masses: bubbly or speckled
OpenStax, Wikimedia Commons

63. X-Rays
Source Undetermined

64. X-Rays
Not all
abdominal
masses are
stool
Source Undetermined

65. X-Rays
Source Undetermined

66. X-Rays
Source Undetermined

67. Lab Studies
• Indicated only as dictated by the
history and physical examination
• Known diuretics: hypokalemia
• Known carcinoma: hypercalcemia
• Blood: low hemoglobin
• WBC count: not specific or helpful
• Thyroid functions: if suggestive

68. Chronic Constipation
• Determine specific reason for this
visit
• Provide symptomatic relief
• Refer to private physician for
continued evaluation, therapy

69. Morbidity and Mortality
• Most bad outcomes: missed
diagnosis of bowel obstruction or
perforation
• Be liberal with x-ray if uncertain

70. Complications of Constipation
• Nonobstructive (straining at stool,
intrathoracic pressure changes):
hernias, GE reflux, decreased
coronary, cerebral, peripheral
arterial circulation
• Obstructive: fecal impaction,
idiopathic megacolon, volvulus,
intestinal obstruction

71. Complications of Constipation
Idiopathic Megacolon
Source Undetermined

72. Complications of Constipation
Megacolon
Source Undetermined

73. Complications of Constipation
Volvulus
Source Undetermined

74. Empiric Management
• Eradicate underlying cause
• Provide symptomatic therapy
–Adequate fluid / fiber intake
–If necessary: synthetic bulk agents

75. Fiber vs. Roughage
• Fiber: primarily from grains and
bran cereals, increases fecal bulk
• Roughage: from most fruits and
vegetables, low bulk
• Psyllium (Metamucil®, Fiberall®)
• Methylcellulose (Citrucel®)
• Both form viscous liquid, promote
peristalsis

76. Fiber: Side Effects
• Common: flatulence, bloat, cramp
• Bacterial metabolism of bran can
form methane gas
• Bulk agents: require adequate fluid
intake or worsen constipation
• Can decrease absorption of
salicylates, nitrofurantoin,
diuretics, tetracyclines

77. Lubricants
• Oral mineral oil helpful if acute
painful perianal lesions
• Less painful passage: soft, coated
stool

78. Lubricants
• Usually well tolerated
• Contraindicated in dysphagia:
aspiration can cause lipid
pneumonia

79. Stool Softeners
• Docusate: Colace®, Surfak®
• Wetting agents, believed to
enhance fecal moisture content

80. Stool Softeners
• As effective as placebo, no better
than other methods
• Can be hepato-toxic, enhance
absorption of other liver toxins
• No chronic use

81. Irritants
• Short-term: benefit if diminished
gut motility (constipating drugs,
hypokalemia, immobility)
• Chronic use limited to
–Weakened abdominal muscles
–Diminished bowel motility from
necessary medications
–Loss of rectal reflexes
–Delayed gut transit or megacolon

82. Osmotic Agents
• Often used for colon prep for
bowel procedures
• In combination with activated
charcoal to prevent briquettes

83. Osmotic Agents
• Lactulose: disaccharide formed
from one molecule each of the
simple sugars fructose and
galactose
• Metabolites draw water into bowel,
causing cathartic effect through
osmotic action

84. Osmotic Agents
• Sorbitol (AKA glucitol): slowly
metabolized sugar alcohol
• Draws water into large intestine 
stimulates bowel movement

85. Osmotic Agents
• Magnesium hydroxide: Phillips'
Milk of Magnesia®
• Causes fluid retention, distends
colon, increases peristaltic activity

86. Osmotic Agents
• Decreases
effect of iron
salts, digoxin,
tetracyclines,
indomethacin
• Avoid in renal
failure

87. Osmotic Agents
• Polyethylene glycol
• Colonic lavage solution used as
bowel prep
• Effective in treating fecal impaction

88. Suppositories
• Especially helpful in patients with
trouble expelling soft stool
• Glycerine: may be soothing, help
patient with constipation from
painful perianal lesions

89. Enemas
• Tap-water or oil-retention: helpful
with disimpaction
• Routine use if failed outpatient
laxatives
• Repeated enemas damage
myenteric plexus, cause motility
dysfunction

90. The Illinois Enema Bandit
The Illinois enema bandit
I heard he’s on the loose
Lord, the pitiful screams
Of all them college-educated women...
Boy, he’d just be tyin’ ’em up
(they’d be all bound down!)
Just be pumpin’ every one of ’em up
with all the bag fulla
The Illinois enema bandit juice

91. Milk and Molasses
“One of the most powerful enemas
that I have experienced is the "milk
and molasses" enema ("M&M," for
short). Use equal amounts of milk
and the "blackstrap" variety of
molasses (it is a strong-flavored
type often used in baking).”
- continued

92. Milk and Molasses
“You won't need a large volume; a
pint of each would be sufficient. Put
the milk in a saucepan and bring to
a boil, then add the molasses,
remove from heat, and stir
thoroughly. When the mixture cools
to about 105o, it is ready to
administer.”

93. Milk and Honey
2 cups milk
16 oz. honey
4 egg whites
“Blend ingredients, then heat in a
small saucepan to 105o. Very nice
for punishment, heavy cramping.”
www.frugaldomme.com

94. Manual Disimpaction
• May be
acutely
necessary
Source Undetermined

95. Manual Disimpaction
Source Undetermined Source Undetermined

96. Manual Disimpaction
Source Undetermined Source Undetermined

97. Manual Disimpaction
Source Undetermined Source Undetermined

98. Manual Disimpaction
Source Undetermined
Source Undetermined

99. Laxative Abuse
3% sodium hydroxide turns stool
red, and hydrochloric acid
reverses red…
…demonstrates phenolphthalein,
most commonly abused laxative

100. Laxative Abuse
Overzealous laxative use:
• Cathartic colon: "pipe stem"
lacking haustra and mimicking
ulcerative colitis
• Melanosis coli: brown pigment
deposits in mucosa, seen on
endoscopy and colonic biopsy

101. Artificial Sphincter
Hernan Montez, Wikimedia Commons

102. Disposition
• Usually can be discharged if
treatment plan in place for acute
constipation, adequate teaching
about prevention
• Fecal impaction, megacolon,
volvulus, bowel obstruction: admit
for further intervention

103. Disposition
• No apparent cause: treat
symptoms, refer for outpatient
diagnostic evaluation
–Sigmoidoscopy, barium enema (air
contrast) to evaluate for underlying
intrinsic bowel lesion
–Endocrinologic metabolic causes

104. Conclusions
• Most important part of evaluation
is the history
• Most constipation can be treated
by correcting the “4 Ds” – diet,
deficient fluid intake, deficient fiber
intake, drugs