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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, July 11, 2016

Start asking the question - What is causing CONSTIPATION?

Constipation is defined as either stool frequency of < 3 times per week or difficulty in passing stools. It is a quite frequent presenting complaint in the ED and many of us treat it like a trivial issue. However, there are a few life-threatening conditions which might present with the chief complaint of constipation. Often it is seen in the elderly and those with multiple medical problems, complicating both their assessment and treatment. 

Key Questions:
  • What do you exactly mean when you say "I am constipated?" (Dig into the frequency, amount, caliber of stools)
  • Associated Symptoms (Tenesmus, Blood in stools, pain while defecating, Weight or Appetite changes, Pain Abdomen, Nausea/Vomiting, Alternating Diarrhea)
  • Duration of constipation (Acute v/s Chronic)
  • Ask for any neurological disease, thyroid disease, diabetes, spinal cord pathology?
  • Medications? (Opioids, Anticholinergics,CCBs, Diuretics, Iron, Aluminium Antacids, NSAIDs)
  • Lifestyle (Bed Ridden, Dietary intake of Water and fibre, Sedentary)

Causes of Constipation (Life Threats)
  • Bowel Obstruction
  • Perforated Viscus
  • Bowel Ischemia
  • HypoK, HyperCa
  • Inflammatory Bowel Disease
  • Diverticulitis
  • Diet and Lifestyle
  • Renal Failure, Hypothyroidism
  • Pregnancy 
  • Painful lesions (haemorrhoids, fissures)
  • Irritable Bowel Syndrome
  • Laxative Abuse
  • Neuro Disorders (Spinal Cord Disease, Multiple Sclerosis, Parkinson's, Diabetes)
  • Medications!

What labs do need to order?
  • CBC 
  • Electrolytes 
  • Renal Function
  • TSH
  • AXR (suspected bowel obstruction) - Read more on this at LIFTL

Those who look stable, normal vital signs and a BENIGN abdominal exam can be worked up as an out-patient. Treat with laxatives once bowel obstruction had been ruled out. 

Have a "discharge conversation", discuss your concerns and advise on dietary and lifestyle habits and appropriate follow up. 

Take Home
  • Start asking the question - What is causing CONSTIPATION?
  • Common cause include lifestyle habits, dietary factors and medications
  • Faeces seen on plain radiographs is normal. Imaging should be used to exclude other pathologies.

     Lakshay Chanana

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