Everybody poops. The importance of regular bowel movements has been recognized for centuries, including the scholar Moses Maimonides, “Man should always strive to have his intestines relaxed all the days of his life… whenever the stool is withheld or is extruded with difficulty, grave illnesses result.” This session is intended for anyone who poops or cares for people who poop. Audience members will learn the key historical questions to ask for patients of all ages who present to the emergency department with a complaint of constipation. We will review ‘can’t miss’ diagnoses and what conditions should be on your differential. Though both you and the patient may find it uncomfortable, a rectal exam is a key part of the physical exam for adults in this setting. I will address the utility of diagnostic tests for patients with constipation, including the contentious abdominal X-ray. While an X-ray can be useful to evaluate for free air, radio-opaque foreign body, and intestinal volvulus, the utility in assessing a patient with constipation is questionable at best. Even in children, this study is frequently misinterpreted and fraught with peril.
I will teach a simple therapeutic algorithm for patients in whom you suspect chronic idiopathic or medication-related constipation. While many over-the-counter and prescription medications are available for chronic constipation, they generally all belong in two categories, which I refer to as ‘mush’ and ‘push.’ The former category includes bulking agents like dietary fiber and psyllium, as well as numerous other osmotically active substances such as polyethylene glycol, lactulose, and magnesium. Once confident that the stool is being sufficiently softened, you can add an agent that stimulates the enteric nervous system, including senna and bisacodyl. If this two-step approach has not produced the desired effect, next steps include suppositories, biofeedback, and digital stimulation. Some patients may be prescribed laxative medications such as linaclotide or lubiprostone, but these generally fall outside the scope of emergency medicine. The audience will leave this session armed with the tools to evaluate the constipated patient and an evidence-based method for getting bowels moving again.