Constipation

📚Definitions 

Constipation is generally characterized by two or more of the following:

• Fewer than three bowel movements per week.
• Hard, dry, or lumpy stools.
• Difficulty or pain when passing stools.
• Feeling that not all stool has passed.

🗺️ Overview

Constipation is a symptom rather than a defined disease. When evaluating patients with known or suspected constipation, the goal of the visit is to characterize the condition while noting possible related issues or diseases. A history and physical examination should be performed to guide initial treatment as well as identify alarm signs or symptoms. Educating the patient is an important aspect of the visit.

🚨 Important History

• Nature of symptoms:
  • Duration and timing of symptoms.
  • Stool consistency, frequency.
  • Presence of blood streaking or mixed.
  • Straining.
  • Avoiding/delaying bowel movements with posturing or positional changes.
  • Fatigue, irritability, or changes in appetite related to bowel patterns.
  • A swollen abdomen, cramps, or bloating.
  • Pain associated with or relieved by bowel movements.
  • Urinary incontinence.
• Medications:
  • Pharmaceutical agents or supplements to aid bowel movements.
  • Drying agents, agents which reduce gut motility (e.g., opioids, anticholinergics, iron supplements, antidepressants).

• Diet and water intake:

•  
  • Fiber content.
  • Recent changes in diet.
• Exercise level.
• Rectal bleeding or mucus discharge.
• Unexplained weight loss.
• Fever, vomiting.
• Tenesmus or abdominal pain.
• Acute onset of constipation in older adults.
• Change in stool caliber (e.g., "ribbon stools").
• Persistent constipation unresponsive to treatment.
• Personal or family history of colon cancer, inflammatory bowel disease, or other gastrointestinal disorders.
• Lead exposure.

📹 Video Examination 

• Vitals: Temperature, height, and weight.
• General Appearance:
  • Body habitus.
  • Signs of discomfort or distress.
  • Difficulty with ambulation (patient's self-report may be adequate).
• Skin and hair:
  • Pallor, jaundice, or other skin changes.
  • Thinning of lateral eyebrows.
  • Unusually dry skin.
  • Hair loss.
• Abdomen:
  • Ask the patient to point with one finger to the site of any pain or discomfort.
  • Ask the patient to tap over their flanks and describe any tenderness.
  • Guide the patient in the Heel Drop test.
  • Observe while the patient palpates the abdomen in four quadrants.
  • Note abdominal distention, visible masses.
• Extremities:
  • Edema, skin changes.

🎯 Diagnosis 

Constipation can be classified as Primary (Functional) or Secondary. Differentiation is relevant because it guides treatment.

Functional Constipation

• Not associated with abdominal pain.
• Ongoing symptom duration >6 months in adults.
• Not due to medication side effects or another medical condition.

Secondary Constipation

• Constipation with one or more known or suspected identifiable causes. Common causes include:
  • Medications: Opioids, anticholinergics, iron supplements, antidepressants, chemotherapy, aluminum-containing antacids.
  • Endocrine issues: Diabetes, hypothyroidism.
  • Food sensitivities: Gluten sensitivity.
  • Neurophysiologic disorders.
  • Pregnancy.

💆 Treatment 

Constipation is usually easier to prevent than to treat. The mainstay of prevention includes:

• Adequate exercise.
• Adequate fluid intake.

• High-fiber diet.

   

Pharmacological Management

First-Line Therapies

• Bulk laxatives (e.g., psyllium, methylcellulose): First-line therapy for chronic constipation.
• Osmotic laxatives (e.g., polyethylene glycol [PEG], lactulose, sorbitol): Used for short-term relief if bulk laxatives are ineffective.

Second-Line Therapies

• Stimulant laxatives (e.g., bisacodyl, senna): For occasional use in refractory cases.
• Lubricants (e.g., mineral oil): For short-term use.

Special Considerations

• Saline laxatives (e.g., magnesium hydroxide): Use with caution due to risk of electrolyte imbalances.
• Enemas: Reserved for severe cases; warm water enemas preferred in older adults.
• Prescription medications (e.g., lubiprostone, linaclotide, plecanatide): For chronic idiopathic constipation; not for urgent care.

Pregnant and Nursing Women

• Refer to obstetrician for management, as many medications are not considered first-line.

🧪 Diagnostic Tests

• Lab tests: Consider if ruling out hypothyroidism, electrolyte disturbances, or other underlying conditions.

   

• Radiologic tests (e.g., KUB): Rarely indicated unless obstruction is suspected.

 🔮 Follow Up 

• Patients should be referred for in-person care if they exhibit alarm symptoms, fail to respond to therapy, or require further evaluation.

   

• Routine or conditional follow-up may be necessary for chronic or recurring cases.

   

📩 Referral Indicators 

• Refer to gastroenterology for persistent or severe cases, or if secondary causes are suspected.

📘 Coding

ICD-10 Codes

• K59.00: Constipation, unspecified.
• K59.09: Other constipation.
• R15.0: Incomplete defecation.
• R15.2: Fecal urgency.
• R19.4: Change in bowel habit.

If you have any questions or would like more information, please reach out to the Delegating Physician.