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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, July 11, 2016

Start asking the question - What is causing CONSTIPATION?


Definition
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.
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Author:

              
     Lakshay Chanana
     @EMDidactic
                                                        




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