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Refractory Constipation: A Case Study in Evaluation and Management

Refractory Constipation: A Case Study in Evaluation and Management

A presentation on October 13, 2013, at the American College of Gastroenterology Annual Scientific Meeting by Satish Rao, MD (Georgia Regents University, Augusta, GA):

Rao SS. Management of Refractory Constipation

In this ACG 2013 session, Satish Rao, MD, gives us an approach to prevent the increasing numbers of hospital admissions for constipation that speaker Saurabh Sethi, MD, documented in his study, presented the following day.

Constipation is often treated as a simple functional disorder that responds well to improvements in diet, hydration, and exercise. And usually, that’s appropriate. For most elderly people, some degree of functional constipation is fairly routine, and they and their doctors tend to work through it. But Dr Rao is a consultant—so he sees the difficult cases. The one he comes back to over and over again in this discussion is a younger patient who ended up with an extensive workup. Most routine cases won’t need this. But all will need a bit of careful attention—or they can end up as one of Dr Sethi’s admission statistics.

Dr Rao’s case presentation concerned a 40-year-old woman, employed as a nurse, with chronic constipation that worsened over the past 2 years. She has only weekly, hard bowel movements, with straining but no hematochezia. Multiple laxative trials have produced diarrhea followed by absent bowel movements for up to 2 weeks. She has recurrent right lower quadrant pain that radiates superiorly, worsening postprandially and after evacuation. She has chronic bloating and gas, worsening postprandially. Her quality of life has declined, and she has missed weeks at work.

Results of basic laboratory screen, anoscopy/colonoscopy, CT scan, EGD, and MRI of spine have all been normal. Physical exam is unremarkable, including intact anocutaneous reflex, with adequate resting and squeezing anal tone. There was good perineal descent, but incomplete relaxation.

At this point, the differential diagnosis included:
• Colonic inertia
• Severe slow-transit constipation (STC)
• Dyssynergic defecation
• Carbohydrate malabsorption
• Opioid abuse (remember, this is a health care worker)

Which do you suspect? Click here to read on.

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