Emergency Department Evaluation and Management of Constipation (Palliative Care CME)

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Delivery Method:	Online
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Publication Date: March 2024 (Volume 26, Number 3)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 03/01/2027.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Palliative Care CME credit, subject to your state and institutional approval.

Author

Peer Reviewers

Abstract

Each year, over 1.3 million patients visit the emergency department for constipation. Most cases are benign, but serious complications, such as fecal impaction and stercoral colitis, must be ruled out. Evidence to guide the evaluation and treatment of constipation in the emergency department is limited, and many of the decades-old treatments have not been studied in modern, rigorous, controlled trials. In the emergency department, constipation is a clinical diagnosis, and ideal management includes excluding dangerous mimics or complications and, for most patients, discharging the patient with a bowel regimen tailored to the likely cause of their constipation, with appropriate referral to primary or specialty care. This review evaluates consensus guidelines on management of constipation as well as the early data on the newer prescription medications for chronic and opioid-induced constipation.

Case Presentations

An 85-year-old woman with altered mental status is brought in by ambulance from a nursing home…

• The patient has a history of diabetes, stroke, and mild dementia. The paramedic transporting her said the nursing home staff said she is usually alert and oriented to person and place, but today she is lethargic and barely talking. She hasn’t had a bowel movement in 5 days, even after getting an enema yesterday.
• On examination, she is tachycardic, with a nontender but mildly distended abdomen. Her vital signs are: temperature, 37.3°C; heart rate, 114 beats/min; blood pressure, 104/58 mm Hg; and oxygen saturation, 94% on room air.
• As you begin the workup, you wonder whether an episode of simple constipation could make someone this sick…

A 50-year-old man with end-stage renal disease presents with 3 days of constipation…

• The patient says he feels “totally backed up,”despite using stool softeners and fiber supplements regularly. He would like a prescription for something to “get things moving again.”
• After further history and physical examination suggest no other concerning process, you consider an array of laxative options. You wonder which medication is most likely to be effective and affordable, and whether his history of renal dysfunction should influence your choice...

A 40-year-old man presents with lower abdominal pain that has been intermittent for months…

• The patient said that he takes oxycodone daily for chronic back pain, and even though he has tried “every laxative in the store,” he routinely goes a week without relief.
• His vital signs are normal, and his examination demonstrates a soft, nontender, and nondistended abdomen with present but hypoactive bowel sounds.
• You recognize that the likely etiology of his symptoms is opioid-induced constipation, and you wonder whether there are any options you can recommend other than what is available over the counter…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.