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You are called to the bedside of a 79-year-old male patient for evaluation of his altered mental status. The patient is a nursing home resident, now POD 3 from a right total hip replacement, with complaints of abdominal distention and diffuse crampy abdominal pain for two days. There is no record of him having had a bowel movement since being admitted from his nursing home four days ago. A review of the patient’s medication list reveals the addition of acetaminophen/hydrocodone for pain control. He was started on a general diet and his home verapamil, furosemide, and clonidine today but was not given any of his home over-the-counter medications (including Miralax and Metamucil). There is no nausea or vomiting, vital signs are WNL and stable, and the patient has adequate urine output. He is passing flatus on a regular basis. On examination, his abdomen is distended but soft and mildly tender to palpation diffusely.

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1. What should be included in the initial evaluation of this patient?

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2. What additional testing (labs, imaging) could help guide your management?

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Constipation

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Constipation as described by individual patients varies widely but is generally defined by decreased frequency (less than 3 bowel movements per week) and/or symptoms such as straining, passage of lumpy or hard stool, sensation of blockage or obstruction, need for manual assistance (digitations or splinting), and sensation of incomplete evacuation (in >25% of stools).

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Rome III criteria provide some standardization when enrolling patients in clinical trials.

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Rome III Criteria for Functional Constipation
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Diagnostic criteria (criteria fulfilled for the past 3 months with symptom onset at least 6 months prior to diagnosis):

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  1. Must include 2 or more of the following:

      1. Straining during at least 25% of defecations

      1. Lumpy or hard stools in at least 25% of defecations

      1. Sensation of incomplete evacuation for at least 25% of defecations

      1. Sensation of anorectal obstruction/blockage for at least 25% of defecations

      1. Manual maneuvers to facilitate at least 25% of defecations (eg, digital evacuation, support of the pelvic floor)

      1. Fewer than 3 defecations per week

  2. Loose stools are rarely present without the use of laxatives.

  3. Insufficient criteria for irritable bowel syndrome.

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At-risk populations include the elderly, especially hospitalized or nursing home residents, and women, who are diagnosed 3 times more commonly than men. A western diet, low in dietary fiber, and inadequate fluid intake combined with prolonged immobility or a generally sedentary lifestyle all contribute to the development of constipation.

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Other common causes of constipation include:

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  1. Medication side effects:

      1. Opiates—slow transit causing increased desiccation of stool

      1. Antihypertensives, especially calcium channel blockers (verapamil)

      1. Diuretics (furosemide)

      1. Anticholinergics (including antihistamines and many antidepressants)

      1. Iron supplements

      1. Antacids with calcium or aluminum, calcium supplements

      1. Antidiarrheal agents

      1. Long-term laxative use/abuse

      1. NSAIDs

  2. Medical conditions:

      1. Hypothyroidism

      1. Diabetes

      1. Lupus

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