Rosen & Barkin's 5-Minute Emergency Medicine Consult (173 page)

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Red eye

CODES

• 077.99 Unspecified diseases of conjunctiva due to viruses
  
• 372.03 Other mucopurulent conjunctivitis
  
• 372.30 Conjunctivitis, unspecified
  

BASICS

Rome Criteria
for the diagnosis of constipation requires 2 or more of the following for at least 3 mo:

• Straining >25% of the time
  
• Hard stools >25% of the time
  
• Incomplete evacuation >25% of the time
  
• 2 or fewer bowel movements per wk
  

• 3% of pediatric outpatient visits are because of defecation disorders.
  
• Children with cerebral palsy often develop functional constipation.
  
• Can be classified into subgroups:
  
  • Constipation with anatomical origins (anal stenosis/strictures, ectopic anus, imperforate anus, sacrococcygeal teratomas)
    
  • Colonic neuromuscular disease (Hirschsprung disease)
    
  • Defecation disorders (functional constipation and nonretentive fecal soiling)
    
  • Function fecal retention
    
• Most common cause of fecal retention and soiling in children is functional fecal retention:
  
  • Caused by fears associated with defecation
    
  • Associated with irritability, abdominal cramps, decreased appetite, early satiety
    

• Metabolic and endocrine:
  
  • Diabetes
    
  • Uremia
    
  • Porphyria
    
  • Hypothyroidism
    
  • Hypercalcemia
    
  • Pheochromocytoma
    
  • Panhypopituitarism
    
  • Pregnancy
    
• Functional and idiopathic:
  
  • Colonic irritable bowel syndrome
    
  • Diverticular disease
    
  • Colonic inertia
    
  • Megacolon/megarectum
    
  • Pelvic intussusception
    
  • Nonrelaxing puborectalis
    
  • Rectocele/sigmoidocele
    
  • Posthysterectomy syndrome
    
  • Descending perineum
    
• Pharmacologic:
  
  • Analgesics
    
  • Anesthetics
    
  • Antacids
    
  • Anticholinergics
    
  • Anticonvulsants
    
  • Antidepressants
    
  • Antihypertensives
    
  • Calcium channel blockers
    
  • Diuretics
    
  • Ferrous compounds
    
  • Laxative abuse
    
  • MAOIs
    
  • Opiates
    
  • Paralytic agents
    
  • Parasympatholytics
    
  • Phenothiazines
    
  • Psychotropics
    
• Neurologic:
  
  • Central Parkinson disease
    
  • Multiple sclerosis
    
  • Cerebrovascular accidents
    
  • Spinal cord lesions/injury
    
  • Peripheral Hirschsprung disease
    
  • Chagas disease
    
  • Neurofibromatosis
    
  • Autonomic neuropathy
    
• Mechanical obstruction:
  
  • Neoplasm
    
  • Stricture
    
  • Hernia
    
  • Volvulus
    

DIAGNOSIS

• Constipation is a symptom, not a disease.
  
• Passage of hard stool
  
• Straining/difficulty passing stool
  
• Infrequent bowel movements
  
• Abdominal distention/bloating
  
• Firm/hard stool on digital rectal exam:
  
  • May have empty rectal vault
    
• Diarrhea (liquid stool passes around firm feces)
  

• Age of onset of symptoms
  
• Diet and exercise regimen
  
• Stool size, caliber, consistency, frequency, ease of defecation
  
• Medical and surgical history:
  
  • Medications that can slow colonic transit like β-blockers, high-dose calcium channel blockers, narcotics
    
• Use of enemas, laxatives, and digital manipulation to facilitate defecation
  
• Associated pelvic floor dysfunction:
  
  • Urinary symptoms
    
  • Rectocele
    

• Abdominal exam may reveal a mass due to stool
  
• Rectal exam to assess for outlet obstruction:
  
  • Ability to squeeze and relax the sphincter
    
  • Is there a rectocele or cystocele?
    
  • Assess firmness of stool
    

Thorough history and physical exam:

• Medical, surgical, and psychiatric investigation and date of onset
  
• Note abdominal distention, hernias, tenderness, or masses
  
• Complete anorectal exam for anal stenosis, fissure, neoplasm, sphincter tone, perineal descent, tenderness, spasm
  

• Only necessary when considering metabolic/endocrine disorders
  
• CBC if inflammatory or neoplastic origin
  
• Electrolytes and calcium indicated if at risk of:
  
  • Hypokalemia
    
  • Hypocalcemia
    
• Thyroid function test if patient appears to be hypothyroid
  

• Rarely indicated unless an underlying process suspected
  
• Abdominal radiograph:
  
  • Large amount of feces in colon
    
  • Dilated colon that needs decompression
    
• CT scan of abdomen/pelvis to r/o perforation in elderly, constipated patient with abdominal pain/fever
  
• Barium/Gastrografin enema study:
  
  • Diverticulosis
    
  • Megarectum
    
  • Megacolon
    
  • Hirschsprung disease
    
  • Stricture from inflammation or tumor
    

• See “Etiology.”
  
• Bowel obstruction
  

TREATMENT

Establish IV access for patients with significant abdominal pain.

IV fluids for dehydrated/hypotensive patients

• Clean out colon:
  
  • Enemas, suppositories
    
  • Manual disimpaction of hard stool
    
  • Laxatives
    
• Maintain bowel regimen:
  
  • Increase noncaffeinated fluids (8–10 cups per day).
    
  • Increase dietary fiber intake (20 g/day).
    
  • Stool softeners
    
  • Exercise
    
  • Change medications causing constipation.
    

• Enemas:
  
  • Fleet: 120 mL (peds: 60–120 mL) per rectum (PR)
    
  • Mineral oil: 60–150 mL (peds: 5–11 yr old, 30–60 mL; older than 12 yr, 60–150 mL) PR daily
    
  • Tap water: 100–500 mL PR
    
• Fiber supplements:
  
  • Methylcellulose: 1 tbs in cup water PO daily to TID
    
  • Psyllium: 1–2 tsp in cup of water/juice (peds: Younger than 6 yr, 1/4–1/2 tsp in 2 oz water or juice; 6–11 yr, 1/2–1 tsp in 4 oz water or juice; older than 12 yr, 1–2 tsp in cup water or juice) PO daily to TID
    
• Laxatives (osmotic):
  
  • Lactulose: 15–30 mL (peds: 1 mL/kg) PO daily to BID
    
  • Polyethylene glycol: 17 g (peds: 0.8 g/kg/d dissolved in 4–8 oz of liquid) PO daily dissolved in liquid
    
  • Milk of magnesia: 2400--4800 mg Mg hydroxide po (peds 6 mo--1 yr: 40 mg/kg Mg hydroxide; 2--5 yr: 400--1200 mg Mg hydroxide; 6--11 yr: 1200--2400 mg Mghydroxide; over 12 yrs: 2400--4800 mg Mg hydroxide) QD or divided bid--qid prn
    
• Laxatives (stimulant):
  
  • Bisacodyl: 10–15 mg PO daily (peds: Younger than 3 yr, 5 mg PR daily; 3–12 yr, 5–10 mg PO/PR daily; older than 12 yr, 5–15 mg PO daily or 10 mg PR daily)
    
  • Senna: 2 tabs PO daily to BID (peds: 2–6 yr, 1/2–1 tab PO daily to BID; 6–12 yr, 1–2 tabs PO daily to BID; older than 12 yr, 2–4 tabs PO daily to BID)
    
• Stool softeners:
  
  • Docusate sodium: 100 mg (peds: 3–5 mg/kg/d in div. doses) PO daily to BID
    
  • Mineral oil: 15–45 mL (peds: 5–15 mL) PO daily
    
• Suppositories:
  
  • Glycerin: 1 adult (peds: Infant, 1 infant suppository) PR PRN