65 year old male with no known past medical history presenting with constipation that has been worsening over the past month. Patient is a daily smoker and has not seen a doctor in twenty-five years. He has tried docusate, senna, and miralax at home with no improvement in symptoms. Last bowel movement was one week ago. He reports decreased appetite and twenty-pound weight loss during this time. Vital signs: Temp 36C, HR 90 bpm, RR 16, O2 Sat 95% on room air. On physical exam the abdomen appears distended and patient with diffuse abdominal tenderness. What is the best next step in management?

A. Mineral Oil Enema and Discharge

B. Administer Magnesium Citrate and consult Gastroenterology

C. Obstruction Series and Manual Disimpaction

D. Mineral oil enema and outpatient GI follow up for colonoscopy

E. Pain control and CT Abdomen and Pelvis with IV Contrast

Answer: E. Pain control and CT Abdomen and Pelvis with IV Contrast. Patients in this age range presenting with new onset constipation should raise concern for malignancy. Given this patient’s smoking history and lack of primary care follow up he is at high risk. Diagnosis in the Emergency Department is made with CT abdomen and pelvis with IV contrast. Management includes consultation with hem/onc and colorectal surgery. Disposition depends on the severity of symptoms and patient’s clinical appearance. Patients with severe obstruction due to malignancy may require admission to prevent perforation.

Other important causes of constipation to consider:

1. Medications- opiates, antihistamines, anti-diarrheals (such as loperamide)

2. Dietary changes- low fiber intake, dehydration, excessive caffeine or alcohol

3. Infection- Diverticulitis vs Appendicitis

4. Structural- SBO vs Volvulus vs Pregnancy vs Hernia vs Intussusception

5. Metabolic- hypercalcemia, hypothyroidism

6. Neuromuscular- Cauda Equina, Parkinsons

7. Congenital- Cystic Fibrosis, Hirschsprung’s Disease

Management includes:

1. Dietary Changes- increased fiber, prune juice

2. Medications

a. Bulk-forming Laxitives (i.e. metamucils)

b. Surfactants (i.e. Docusate)

c. Osmotic Agents (i.e. Miralax, Lactulose, Magnesium Citrate)

d. Stimulants (i.e. Senna, Dulcolax)

3. Suppositories

4. Enema

5. Fecal disimpaction

Farney, R et al. "Constipation Mimics:Differential Diagnosis and Approach to Management." Feb 2019. <http://www.emdocs.net/constipation-mimics-differential-diagnosis-and-app.... 25 July 2020.