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Chapter 78. Constipation

Linda Lee, MD; Eugenie Shich, MD

  1. What are the risk factor(s) for developing constipation in the hospital?

  2. How do you prevent constipation in a hospitalized patient with a history of constipation?

  3. What are the likely causes of new constipation in a hospitalized patient?

  4. What is the treatment of common causes of new constipation?

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Case 78-1

An 82-year-old man with relapsed diffuse large cell lymphoma presents with severe abdominal pain, distention, and vomiting beginning 24 hours ago. The pain is intermittent, crampy, and diffuse. He has not had a bowel movement in 7 days. He has been receiving rituximab for his lymphoma. He has no history of abdominal surgery. He does have a history of thyroid disease, atrial fibrillation, gout, and diabetes.

The patient has a long-standing history of chronic constipation, and has used polyethylene glycol (PEG) 3350 daily for 2 years. When he was hospitalized a week ago, he was given docusate sodium daily instead of his usual regimen. His other medications include warfarin, allopurinol, levothyroxine, glimepiride, and amlodipine.

His physical exam is remarkable for normal vital signs and a moderately protuberant abdomen. There are bowel sounds but no palpable masses. There is mild diffuse tenderness, but no rebound. The rectal exam reveals no stool in the vault. His laboratory tests are normal. An abdominal flat plate shows a large amount of stool in the right and transverse colon.

What are the causes of this man's constipation? What is the best way to manage his constipation acutely and chronically?

Constipation has many meanings, but for the purposes of this chapter, the medical definition of constipation includes one or all of the following: fewer than three bowel movements per week; passing hard, lumpy stools; straining with defecation; or having a sense of incomplete evacuation. Constipation can newly arise in a patient hospitalized for other medical reasons, represent an exacerbation of a chronic problem, be the principal reason for hospitalization, or be a manifestation of an acute, possibly catastrophic, event.

Chronic constipation is a common complaint that compromises quality of life and frequently prompts use of health care services. Constipation results in 2.5 million physician visits and 92,000 hospitalizations per year in the United States. The prevalence of constipation in North America is estimated to range from 2% to 27%, with most studies citing a prevalence of 15%. This variation in prevalence reflects different diagnostic criteria for constipation and study design. The estimated prevalence of constipation in other developed countries is similar to that in North America at 17.1% in Europe, 14.3% in Hong Kong and 16.5% in South Korea. Constipation is reported more often by females (2-3:1 predominance), nonwhites, individuals of lower socioeconomic status, and the elderly (prevalence of 20%–24%). The cumulative incidence of constipation over more than 1 decade is about 1 in 6. This incidence increases dramatically in the setting of certain comorbidities.

Although most individuals with constipation do not specifically seek ...

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