Chronic Constipation in Adults: Assessment and Plan
History, above.
-Established diagnosis with Rome III criteria & reviewed main symptoms.
—Bristol stool type:____
-R/o alarm features.
-Medication review: No Drugs that cause constipation.
–DDx reviewed to identify and treat reversible causes.
PE: Abd. exam and rectal exam (visualization & digital rectal exam) done. Anoscopy routinely in elderly patients.
Labs/Imaging: CBC routinely. CMP, TSH as needed. XR if impaction suspected.
Patient education: Epidemiology, Pathophysiology, medication options and s/e, and complications of constipation discussed.
Treatment
–Non-pharmacologic treatment.
–Pharmacologic treatment.
Colorectal cancer screening recommended when the patient turns 50 years.
Will consider colonoscopy sooner if the patient develops alarm features.
If diaper rash develops, use Desitin cream or zinc oxide cream.
F/u in 6 weeks if no improvement.
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Constipation Pearls
- How to measure transit time (small bowel or colonic).
- “During the DRE, feel for masses or strictures, note sphincter tone, and rule out fecal impaction. Negative DRE findings do not rule out a proximal impaction, and an abdominal x-ray scan is necessary when there is a high degree of suspicion.” Can Fam Phys.
- “Anoscopy should be performed routinely in elderly patients with constipation.” Swanson’s Family Medicine Review E-book.
- “In the absence of other symptoms and signs, only a complete blood cell count is necessary (strong recommendation, low-quality evidence).
Unless other clinical features warrant otherwise, metabolic tests (glucose, calcium, sensitive thyroid-stimulating hormone) are not recommended for chronic constipation (strong recommendation, moderate-quality evidence).
A colonoscopy should not be performed in patients without alarm features (eg, blood in stools, anemia, weight loss) unless age-appropriate colon cancer screening has not been performed (strong recommendation, moderate-quality evidence).” AGA, 2015
Further Reading / References
AGA Position Statement on Constipation. http://www.gastro.org/guidelines/constipation-1
Canadian Journal of Gastroenterology 25.Suppl B (2011): 7B–10B. What Is Chronic Constipation? Definition and Diagnosis.
The gastroenterology report 1.2 (2007): 56–65. All Roads Lead to Rome: Update on Rome III Criteria and New Treatment Options.
Can Fam Physician. 2015 Feb; 61(2): 152–158. Constipation in older adults: Stepwise approach to keep things moving.
Am Fam Physician. 2005 Dec 1;72(11):2277-2284. Treatment of Constipation in Older Adults
Am Fam Physician. 2011 Aug 1;84(3):299-306. Diagnostic Approach to Chronic Constipation in Adults
Am Fam Physician. 2015 Sep 15;92(6):500-504. Management of Constipation in Older Adults
Swanson’s Family Medicine Review E-Book. By Alfred F. Tallia, Joseph E. Scherger, Nancy Dickey.
http://emedicine.medscape.com/article/184704-overview
uptodate.com/contents/management-of-chronic-constipation-in-adults
Gastroenterol Clin North Am. 2008 Sep;37(3):569-86. Dyssynergic defecation and biofeedback therapy. https://www.ncbi.nlm.nih.gov/pubmed/18793997