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

Table of Contents

 

About This Issue

Constipation is a frequent ED complaint, and it is imperative to determine whether it is a cause or complication of a life-threatening condition. For patients experiencing benign constipation, emergency clinicians can help relieve discomfort and prescribe management options or specialty referral. In this issue, you will learn:

The consensus definitions for constipation syndromes: functional constipation, irritable bowel syndrome with predominant constipation (IBS-C), opioid-induced constipation, and occasional constipation.

The medical conditions and medications that can cause or worsen constipation.

The predominant signs and symptoms of 2 of the most dangerous constipation-related conditions: fecal impaction and stercoral colitis.

When abdominal imaging is called for and when it is not.

Enemas, laxatives, stool softener, and fiber: what works, what doesn’t, and when each is appropriate for ED and home use.

How the newer prescription-only constipation medications work, and when they may be an option.

How to manage the growing population with opioid-induced constipation.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
   1. Fecal Impaction
   2. Stercoral Colitis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Abdominal Radiographs
    2. Computed Tomography
    3. Advanced Testing
11. Treatment
    1. Treatment of Fecal Impaction
    2. Treatment of Stercoral Colitis
    3. Enemas
    4. Osmotic Laxatives
       1. Polyethylene Glycol
       2. Lactulose
       3. Magnesium
    5. Stimulant Laxatives
    6. Stool Softeners
    7. Fiber Supplementation
12. Special Populations
    1. Pregnant and Lactating Patients
    2. Pediatric Patients
    3. Patients on Hospice or at End of Life
13. Cutting Edge
    1. Intestinal Secretagogues
    2. Treatment of Opioid-Induced Constipation in the Emergency Department
14. Disposition
15. Summary
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Managing Emergency Department Patients With Constipation
18. Time and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for Management of Emergency Department Patients With Constipation
    2. Clinical Pathway for Treatment and Referral for Adults Discharged from the Emergency Department With a Diagnosis of Constipation
21. Tables and Figures
22. References

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…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathways

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Chang L, Chey WD, Imdad A, et al. American Gastroenterological Association-American College of Gastroenterology clinical practice guideline: pharmacological management of chronic idiopathic constipation. Am J Gastroenterol. 2023;164(7):1086-1106. (Guidelines) DOI: 10.1053/j.gastro.2023.03.214

4. * Rao SSC, Lacy BE, Emmanuel A, et al. Recognizing and defining occasional constipation: expert consensus recommendations. Am J Gastroenterol. 2022;117(11):1753-1758. (Review) DOI: 10.14309/ajg.0000000000001945

7. * Zhou AZ, Lorenz D, Simon NJ, et al. Emergency department diagnosis and management of constipation in the United States, 2006-2017. Am J Emerg Med. 2022;54:91-96. (Cross-sectional study) DOI: 10.1016/j.ajem.2022.01.065

13. * Bharucha AE, Lacy BE. Mechanisms, evaluation, and management of chronic constipation. Gastroenterology. 2020;158(5):1232-1249. (Review) DOI: 10.1053/j.gastro.2019.12.034

23. * Keim AA, Campbell RL, Mullan AF, et al. Stercoral colitis in the emergency department: a retrospective review of presentation, management, and outcomes. Ann Emerg Med. 2023;82(1):37-46. (Retrospective study; 269 patients) DOI: 10.1016/j.annemergmed.2023.02.003

27. * Paquette IM, Varma M, Ternent C, et al. The American Society of Colon and Rectal Surgeons’ clinical practice guideline for the evaluation and management of constipation. Dis Colon Rectum. 2016;59(6):479-492. (Guideline) DOI: 10.1097/DCR.0000000000000599

33. Establishment Registration & Device Listing. 2024. Accessed February 10, 2024. (FDA database)

36. * Peate I. How to perform digital removal of faeces. Nurs Stand. 2016;30(40):36-39. (Review) DOI: 10.7748/ns.30.40.36.s43

46. * Rao SSC, Brenner DM. Efficacy and safety of over-the-counter therapies for chronic constipation: an updated systematic review. Am J Gastroenterol. 2021;116(6):1156-1181. (Systematic review; 41 studies) DOI: 10.14309/ajg.0000000000001222

64. * Farmer AD, Drewes AM, Chiarioni G, et al. Pathophysiology and management of opioid-induced constipation: European expert consensus statement. United European Gastroenterol J. 2019;7(1):7-20. (Guideline) DOI: 10.1177/2050640618818305

69. GoodRx. 2023. Accessed February 10, 2024. (Drug price database)

72. * Hanson B, Siddique SM, Scarlett Y, et al. American Gastroenterological Association Institute technical review on the medical management of opioid-induced constipation. Gastroenterology. 2019;156(1):229-253. (Systematic review; 20 studies) DOI: 10.1053/j.gastro.2018.08.018

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Keywords: constipation, laxative, enema, disimpaction, stercoral colitis, impaction, opioid, IBS