Follow-up
Further Inpatient Care
- Once acute constipation has resolved and the associated medical or surgical conditions have been ruled out, additional inpatient care is rarely indicated.
- Patients requiring surgical intervention for acute conditions, such as large bowel obstruction, volvulus, toxic megacolon, and, rarely, chronically atonic colon that requires colectomy, need postoperative care, but that is beyond the scope of this article.
Further Outpatient Care
- After constipation resolves, outpatient care for the acutely constipated patient requires the following measures:
- To ascertain that the patient is not chronically constipated
- To rule out colorectal pathology
- For the patient who is chronically constipated, outpatient care may include the following:
- Colonic imaging or endoscopic visualization
- Dietary management
- If these measures fail in a compliant patient, further evaluation is indicated.
Transfer
- Generally, transfer is not required unless uncertainty exists concerning the diagnosis or the underlying cause and more aggressive medical evaluation is necessary. Such an eventuality might occur in patients institutionalized in nursing homes or in chronic care facilities who require medical consultations to rule out conditions that are more serious. The following factors may warrant a transfer:
- Uncertain diagnosis
- Evidence of intra-abdominal catastrophe
- Acute abdominal pain
- Fever
- Lower GI bleeding
- Chills
- Instability of vital signs
- Absence of bowel sounds
- Acute recent change in bowel habits
- Unsuccessful or inadequate treatment offered at the local facility
Deterrence/Prevention
- In children and in mentally incapacitated patients with a pattern of bowel retention, resolution of this pattern requires aggressive short-term use of laxatives, stool softeners, and local care of any anal fissures. Once this pattern has been unlearned, usually within several weeks, laxatives should be gradually tapered off while the use of fiber and fluid supplementation should indefinitely continue.
- Failure to taper the laxatives without the return of constipation indicates the need for a gastroenterologic consultation to rule out an underlying problem.
Complications
- Generally, hemorrhoids are medically managed. Surgical intervention is reserved for when medical management fails.
- Generally, fissures are medically managed. Surgical intervention is reserved for when medical management fails.
- Fistulae-in-ano require surgical therapy.
- The chronic pressure effect of hard stools against the anterior rectal wall when the patient strains during defecation is believed to cause solitary rectal ulcers. This is usually a self-limiting process and responds to treatment for constipation. In adults, surgical or gastroenterologic consultation may be required to differentiate benign solitary rectal ulcers from rectal malignancy.
- Melanosis coli from prolonged laxative use is an incidental finding at endoscopy.
Prognosis
- With appropriate dietary management, prognosis in most patients is excellent. Recurrence depends on the patient's long-term compliance to therapy.
- After a careful preoperative workup that includes physical and psychological assessment, patients with outlet obstruction generally respond well to surgical correction and have a good prognosis.
- Dyskinesias of the pelvic floor musculature and of the sphincter mechanism may be managed via biofeedback therapy, but the results are mixed.
- Patients who are chronically dependent on increasing doses of self-prescribed laxatives are perhaps the most difficult patients to treat.
- Most patients can be treated with a combination of fiber, water, and osmotic agents, such as sorbitol. However, the need for increasing doses of laxatives and the intermittent use of other agents becomes problematic.
- In rare situations in which patients are virtually refractory to laxatives, total abdominal colectomy may be performed after careful workup. Postoperatively, these patients often experience a greatly improved quality of life. A careful preoperative evaluation and a detailed informed consent discussion are required.
Patient Education
- The prognosis is excellent for patients who implement dietary changes.
- Dietary deficiency requires increased fluid and fiber supplementation for life.
- For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Constipation in Adults and Constipation in Children.
Miscellaneous
Medicolegal Pitfalls
- Failure to identify colorectal cancer
- Overlooking an anal fissure in a constipated child
- Misdiagnosing colonic ileus secondary to sepsis or an intra-abdominal catastrophe as constipation
- Misdiagnosing large bowel obstruction as constipation
- Surgical intervention for constipation in a patient with an underlying psychiatric cause
Special Concerns
- Pregnant women are frequently constipated because of dietary alterations, anatomical impingement of a large uterus on the rectosigmoid, fluid shifts, and decreased exercise and mobility. Typically, these women develop hemorrhoids from passive venous congestion and uterine impingement. Pregnancy-related constipation potentiates the development of symptomatic hemorrhoids, and the resolution of constipation is the only available antihemorrhoidal therapy during pregnancy.
- First-line treatment is fiber supplementation, increased water intake, gentle exercise, and occasional laxative use as required.
- Hemorrhoidal suppositories and sitz baths may offer symptomatic relief.
- Attentive management is particularly important to minimize acute and subacute hemorrhoidal complications induced by the straining associated with vaginal delivery.
- Elderly patients appear particularly prone to constipation. The rate of self-reported constipation rapidly increases in patients older than 65 years.
- Careful review of prescribed medications may reveal 1 or more that may potentiate constipation.
- Manipulating their diets and encouraging patients to exercise are the cornerstones of treatment.
- Laxatives may be required, particularly in patients with a history of chronic laxative abuse.
- Constipation in children is frequently diet-related, particularly toddlers who are being switched from formula feeds to milk. Small children are especially liable to develop constipation that is more prolonged. This is associated with painful bowel movements caused by an acute anal fissure, which forces the child to avoid bowel movements.
- Painful defecation produces a vicious positive feedback cycle. The child suppresses the urge to defecate, resulting in a larger and harder stool. When the stools eventually emerge, the pain of defecation is worse, encouraging the child to retain the stools further.
- Prescribing long-term laxatives for a period of several weeks may be necessary in order to force the child to defecate daily until the cause of the anorectal pain is resolved and the fecal retention behavior is unlearned.
- The first-line therapy remains dietary manipulation, with increased fluid intake and the use of dietary fiber via fruits and vegetables or supplementation with more purified forms of fiber, such as wheat germ, psyllium, methylcellulose, or agents like Maltsupex. These may be mixed with liquids and administered with the help of a child's feeding bottle.
More on Constipation |
| Overview: Constipation |
| Differential Diagnoses & Workup: Constipation |
| Treatment & Medication: Constipation |
 Follow-up: Constipation |
| References |
| Further Reading |
| « Previous Page |
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Further Reading
Clinical guidelines
Functional constipation and soiling in children.
University of Michigan Health System - Academic Institution. 1997 Sep (revised 2008 Sep). 15 pages. NGC:006843
ASGE guideline: guideline on the use of endoscopy in the management of constipation.
American Society for Gastrointestinal Endoscopy - Medical Specialty Society. 2005 Aug. 3 pages. NGC:004485
Prevention of constipation in the older adult population.
Registered Nurses' Association of Ontario - Professional Association. 2002 Jan (revised 2005 Mar). 56 pages. NGC:004213
Practice parameters for the evaluation and management of constipation.
American Society of Colon and Rectal Surgeons - Medical Specialty Society. 2007 Dec. 10 pages. NGC:006460
Clinical trials
An Open-Label, Long-Term Safety Study of Linaclotide in Patients With Chronic Constipation or Irritable Bowel Syndrome With Constipation
Intestinal Microecology in Chronic Constipation
Lubiprostone (Amitiza®) Vs. Standard Care in Opioid-Induced Constipation After Surgery in Inpatient Rehabilitation
Effectiveness of Docusate in Preventing/Treating Constipation in Palliative Care Patients
Related eMedicine topics
Constipation (Pediatrics: General Medicine)
Constipation (Emergency Medicine)
Constipation and Bowel Management
Hirschsprung Disease
Rectal Prolapse
Keywords
constipation, bowel movement, diverticular disease, defecation, anorectal manometry, hemorrhoid, anal fissure, hemorrhoidal disease, thrombosis hemorrhoid, rectal tumor, bowel motility, laxative abuse, colonic tumor, rectal prolapse, colonic ileus, obstipation, defecography, anismus, large bowel obstruction, ischemic bowel
