TAM (Treatments and Medicines) NHS Highland
Beware: constipation, a common symptom, but it sometimes heralds a surgical emergency.
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Emergency admission of adults with acute constipation
Patients admitted to surgical unit with a chief complaint of acute "constipation" or obstipation, with or without abdominal pain.
High risk groups
- Older adults.
- Those taking opiates or other medication known to cause significant constipation.
- Significant neurological pathology, ie Parkinsons/MS.
- Significant impaired mobility.
- Or where there is a history of GI pathology/surgery.
Hence importance of:
- Abdo and digital rectal exam.
- Discussion re treatment escalation plan / ceiling of care.
- Imaging: ?AXR, ?CT.
- Is there gas all the way to the rectum, or is there a transition point?
- Is there the classic 'coffee' bean of volvulus?
- +/- flexible sigmoidoscopy with caution?
Differentiation
- It is important to differentiate between 1, 2, & 3.
- Remember occasionally 1 may lead to 2, ie faecal impaction.
- And note, constipation may present as a secondary urinary retention.
1. Functional problem
- Often a precipitant: Have they had their simple laxatives?
- Often acute or chronic.
- Sometimes "pseudo-obstruction".
- Have they been investigated for slow transit, or obstructed defecation syndrome, or mega-rectum / mega colon?
2. Mechanical obstruction
- Always think of ?
- Colorectal tumor.
- ? other structure or extrinsic compression.
- ? volvulus.
- ? impaction.
- May still have overflow diarrhoea.
3. Toxic megacolon
- Remember this may mimic constipation.
- Causes include IBD, C Diff, pseudomembranous colitis, ischaemia.
Treatment
- Enema? Laxatives?
- Treat underlying causes.
- Is it appropriate to investigate later for altered bowel habit?
- See: NICE CKS choice of laxatives.
Treatment
This medical and surgical emergency is another topic.
Impaction
Requires manual excavation, usually in theatre under GA, if fit.
Volvus
Flex sig decompression +/- resection (or PEC tubes) if persistent or recurrent.
Tumour
Resection or stent or stoma.
Other
Other structures, extrinsic compressions: treatment depends on cause.
