A 61-Year-Old Woman With Painful Constipation

Winston Tan, MD; Matthew Tan

Disclosures

October 12, 2017

After any critical illness associated with constipation has been ruled out, manual disimpaction and transrectal enemas are often used. A well-lubricated, gloved finger may be used for this purpose in patients with lower anorectal impactions. Warm-water enemas are not usually necessary in the emergency department. After these measures, elective evaluation for the cause of the constipation is performed.

Enemas, suppositories, and laxatives do not address the underlying problem of constipation. Therefore, medical care should focus on dietary change and exercise. Patients with chronic constipation are at high risk of becoming dependent on laxatives and developing a laxative colon. For most patients, the key to treatment is correction of dietary deficiencies. Encouraging aerobic exercise is a reasonable strategy, although the effectiveness of exercise in patients with constipation is controversial. Brisk walking may help with bowel motility and is unlikely to cause problems in most patients.

Surgery is generally restricted to management of complications or evaluation of underlying causes. If an underlying psychiatric cause is suspected, surgical intervention should be avoided. Patients who present with abdominal pain with acute porphyria have undergone inappropriate surgical procedures, usually owing to an incomplete evaluation and history. Patients with a large-bowel obstruction or colonic ileus secondary to an acute intra-abdominal process should undergo surgical consultation. This consultation is also indicated for patients who have anorectal complications of constipation. Anal fissures and symptomatic hemorrhoids are generally considered complications of constipation. Urgent surgical consultation is required in patients with acute hemorrhoidal thrombosis, in order to achieve pain relief and evacuation of the clot. Patients with anal fissures should undergo conservative management because most fissures respond well to programs involving sitz baths, stool softeners, and anesthetic ointment.

Dietary fiber may also aid patients with constipation. Natural sources include fruits, vegetables, and cereals. Although natural sources are preferred, advising patients to consume more fruits and vegetables is often unsuccessful. Thus, fiber supplements may be used.

If the cause of constipation is opioid use, discontinuation of therapy may be required. Long-term opioid therapy results in opioid-induced constipation in 40%-80% of patients.

In this patient, a biopsy resulted in the specific diagnosis of metastatic breast cancer. Chemotherapy with capecitabine and radiation resulted in dramatic improvement of her symptoms and control of her disease. MRI revealed resolution of her perirectal mass (Figure 2).

Figure 2.

 

Initial treatment was followed by chemotherapy with 5-fluorouracil, epirubicin, and cyclophosphamide (FEC). Taxane-based chemotherapy was avoided owing to the risk of worsening her neuropathy from multiple sclerosis. The patient continues to be in partial remission 4 years later and is receiving monthly maintenance treatment with fulvestrant.

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