eMedicine Specialties > Emergency Medicine > Gastrointestinal

Constipation: Differential Diagnoses & Workup

Author: Dave A Holson, MD, MBBS, MPH, Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine; Director, Department of Emergency Medicine, Queens Hospital Center
Contributor Information and Disclosures

Updated: Aug 5, 2009

Differential Diagnoses

Obstruction, Large Bowel

Other Problems to Be Considered

Diabetes mellitus
Hyperparathyroidism
Hypothyroidism
Uremia
Lead poisoning
Neuropathy
Parkinson disease
Multiple sclerosis
Spinal cord injuries
Scleroderma
Lupus
Amyloidosis

Workup

Laboratory Studies

  • Serum chemistry may exclude any metabolic causes of constipation, such as hypokalemia and hypercalcemia.
  • Complete blood count (CBC) may reveal any anemia that might be associated with rectal bleeding (gross or occult).
  • Thyroid function tests may be helpful with patients suspected of having hypothyroidism.

Imaging Studies

  • Plain film of the abdomen (upright and flat) and an upright chest film
    • These studies underscore the amount of stool present in a patient's colon. Differentiation of fecal impaction, bowel obstruction, and fecalith is possible.


Large amount of stool throughout the colon.

Large amount of stool throughout the colon.

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Large amount of stool throughout the colon.

Large amount of stool throughout the colon.



Large stool mass in hepatic flexure of the colon.

Large stool mass in hepatic flexure of the colon.

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Large stool mass in hepatic flexure of the colon.

Large stool mass in hepatic flexure of the colon.



Colon distension secondary to fecal impaction.

Colon distension secondary to fecal impaction.

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Colon distension secondary to fecal impaction.

Colon distension secondary to fecal impaction.

    • Diagnosis of fecaliths is important because of the dreaded complication of stercoral ulcers, which can lead to colonic perforation. Stercoral perforation is a rare but life-threatening surgical emergency of perforation due to pressure necrosis that can lead to peritonitis.
    • Diabetic gastropathy, as well as fecal impaction, may be seen in patients with diabetic neuropathy.
    • Residual barium (from barium enemas) can be visualized.
    • Scleroderma and other connective-tissue diseases may be complicated by motor disturbances that mimic colonic obstruction on plain film.
    • Myxedema ileus is a consequence of hypothyroidism.

Other Tests

  • An extensive workup of the constipated patient is performed on an outpatient basis and usually occurs after approximately 3-6 months of failed medical management.
  • Anatomic tests include Gastrografin enema, proctosigmoidoscopy, and colonoscopy.
  • Physiologic tests include the following: colonic transit study (which uses radio-opaque markers in patients with suspected slow-transit constipation), defecography (which identifies internal rectal intussusception), and anorectal manometry and surface anal electromyography (which help to confirm pelvic floor dyssynergia or anismus).

Procedures

  • Anoscopy: Routinely perform anoscopy on all constipated patients to visualize anal fissures, ulcers, hemorrhoids, and local anorectal malignancy.
  • Digital disimpaction: A well-lubricated gloved finger might be required in patients with lower anorectal impactions.
  • Warm water enemas: These usually are unpopular among the nursing staff and probably are not necessary within the ED.

More on Constipation

Overview: Constipation
Differential Diagnoses & Workup: Constipation
Treatment & Medication: Constipation
Follow-up: Constipation
Multimedia: Constipation
References
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References

  1. [Guideline] Ternent CA, Bastawrous AL, Morin NA, Ellis CN, Hyman NH, Buie WD. Practice parameters for the evaluation and management of constipation. Dis Colon Rectum. Dec 2007;50(12):2013-22. [Medline]. [Full Text].

  2. Sweetser S, Busciglio IA, Camilleri M, Bharucha AE, Szarka LA, Papathanasopoulos A, et al. Effect of a Chloride Channel Activator, Lubiprostone, on Colonic Sensory and Motor Functions in Healthy Subjects. Am J Physiol Gastrointest Liver Physiol. Nov 25 2008;[Medline].

  3. Camilleri M, Kerstens R, Rykx A, Vandeplassche L. A placebo-controlled trial of prucalopride for severe chronic constipation. N Engl J Med. May 29 2008;358(22):2344-54. [Medline]. [Full Text].

  4. Halligan S, Bartram CI. The radiological investigation of constipation. Clin Radiol. Jul 1995;50(7):429-35. [Medline].

  5. Harari D, Gurwitz JH, Avorn J, Bohn R, Minaker KL. How do older persons define constipation? Implications for therapeutic management. J Gen Intern Med. Jan 1997;12(1):63-6. [Medline].

  6. Johanson JF, Sonnenberg A, Koch TR. Clinical epidemiology of chronic constipation. J Clin Gastroenterol. Oct 1989;11(5):525-36. [Medline].

  7. Lembo A, Camilleri M. Chronic constipation. N Engl J Med. Oct 2 2003;349(14):1360-8. [Medline].

  8. Martin H, Slyk MP, Deymann S, Cornacchione MJ. Safety profile assessment of risperidone and olanzapine in long-term care patients with dementia. J Am Med Dir Assoc. Jul-Aug 2003;4(4):183-8. [Medline].

  9. Mezwa DG, Feczko PJ, Bosanko C. Radiologic evaluation of constipation and anorectal disorders. Radiol Clin North Am. Nov 1993;31(6):1375-93. [Medline].

  10. Rantis PC Jr, Vernava AM 3rd, Daniel GL, Longo WE. Chronic constipation--is the work-up worth the cost?. Dis Colon Rectum. Mar 1997;40(3):280-6. [Medline].

  11. Schiller LR. New and emerging treatment options for chronic constipation. Rev Gastroenterol Disord. 2004;4 Suppl 2:S43-51. [Medline].

  12. Shafik A. Constipation. Pathogenesis and management. Drugs. Apr 1993;45(4):528-40. [Medline].

  13. Sonnenberg A, Koch TR. Epidemiology of constipation in the United States. Dis Colon Rectum. Jan 1989;32(1):1-8. [Medline].

  14. Velio P, Bassotti G. Chronic idiopathic constipation: pathophysiology and treatment. J Clin Gastroenterol. Apr 1996;22(3):190-6. [Medline].

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Further Reading

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Keywords

hard stool, constipation, constipation treatment, constipation causes, constipation symptoms, fecal impaction, irregular bowel movement, straining, colonic functional disorder, anorectal functional disorder, functional constipation, pain on defecation, rectal bleeding, thrombosed hemorrhoids, intussusception, irritable bowel syndrome, idiopathic slow transit constipation, chronic intestinal obstruction, rectal outletobstruction, anismus, solitary rectal ulcer, rectocele, weak pelvic floor, Hirschsprung disease

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Contributor Information and Disclosures

Author

Dave A Holson, MD, MBBS, MPH, Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine; Director, Department of Emergency Medicine, Queens Hospital Center
Dave A Holson, MD, MBBS, MPH is a member of the following medical societies: American Academy of Emergency Medicine, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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