Constipation

Pretty regularly, patients come to ERs because they can’t poop. Those of you with bird-like regularity are amazed. Those of you with anaconda-like regularity get it. My worst blockage happened at a week long scout camp as a kid when the latrine was a plank with holes, and my butt said “not happen.” I hadn’t yet learned the hover, and I was miserable. So today, I’m sympathetic.

However, here’s a true confession from the ER trenches… We in ERs offer almost nothing for constipation you can’t do yourself in the comfort and privacy of home. There is really no prescription that I provide that’s better than the OTCs. My contribution is generally to rule out life threats, then provide a list of OTCs, and then comfort patients that they too have a case of the human condition. So please know the buzz words before seeking the emergency colon blow.

Red Flags:

• Vomiting… This is probably the biggest. Bowel obstruction is our concern.
• Fevers… diverticulitis? appendicitis? peritonitis? mesenteric adenitis?
• Localized pain above and beyond typical cramping… “Pain out of proportion to exam” is our description for mesenteric ischemia, which is like a heart attack, but for the intestines.
• Abdominal surgeries… distant past or recent
• Hernias
• Abdominal cancer
• History of diverticulitis, colitis, Crohn’s disease
• Chronic steroid use
• Frail, elderly or pediatric
• Immobile or wheelchair bound

Happy Words

• Recent narcotic use… likely to resolve with movement, time and no more narcotics
• Sedentary at home or at work… likely to resolve with activity
• Still passing gas
• Still eating easily
• “It’s been 24 hours since my last poop… and no, I haven’t tried anything yet.”
• “My CT scan last week said I was FOS (full of stool).”
• “I’m constipated all the time and just need a little help.”

Once we’ve ruled out the life threats, then our treatments are pretty much high dollar OTCs. Colace, magnesium citrate, Miralax, Fleets enemas, Dulcolax suppositories are some of our favorites. Have a look at Fleetslabs.com to see their remarkable range of offerings. Not sure why, but many nurses feel the soapsuds enema is “da bomb.” So head to an ER if you’d like that approach. (Not on the Pre-R menu.)

Personally, I think exercise is more important than all the rest + a high fiber/high prune diet + hydration. Movement is critical. Waiting in bed for constipation to resolve is like riding a roller coaster to cure diarrhea. Won’t happen. Also, do not underestimate the “impact” of narcotics. A single dose can cause a long lasting ripple effect of discomfort, bleeding, anal fissures etc.

Lastly, a shoutout to a great doc/friend in New Mexico, Dr. Justin Hazen, who invented a cocktail years back, affectionately called “Hazen’s Heavy Hitter.” If I remember correctly it was a mix of coffee, chocolate syrup and magnesium citrate. “Do not go in there!” (Name the movie.)

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