CONSTIPATION

LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Identify medications that can exacerbate constipation.

• Describe the advantages and disadvantages of each class of laxatives and discuss the appropriate use
of each class.

• Recommend an appropriate plan for the treatment of constipation, including lifestyle modifications
and drug therapy.

• Educate patients regarding laxative therapy

PATIENT PRESENTATION

Chief Complaint

“I feel just awful ever since starting these pain pills—I think I’d rather be in pain!” HPI Kerry Reynolds is a
64-year-old woman who presents to the ED complaining of increasing abdominal cramping and nausea
for several days and now vomiting for the past several hours. She says this all started when she began
Percocet therapy 2 weeks ago for postprocedural pain in association with right TKA. Her last bowel
movement was 6 days ago. She began “not feeling well” 4 days ago, with bloating, decreased appetite,
decreased thirst, and fatigue. She reports that yesterday, when her cramping was at its worst, she even
used a couple doses of Metamucil, but it did not help. She says she was almost to the point where she
thought about trying some powerful laxatives, but she has heard about the addiction they can cause and
the last thing she wants is to be addicted to a laxative. She has also tried to just quit taking the pain
meds altogether, but she only makes it about halfway through the morning before the pain becomes
unbearable. She reports that she has cut back on the pain pills and is only taking one pill four times a
day now, compared with a week ago when she was taking two pills four times a day. On a scale of 1–10,
with 1 being no pain and 10 being the worst pain ever experienced, she rates her pain at a 5 today. She
does say the pain is improving every day. Her plan is to take one less pain pill every 3 days so that she
can successfully taper the meds in about 2 weeks. She reports no fever, CP, or SOB. She states that she
typically has daily bowel movements, with no straining, and spends less than 10 minutes, with little
effort, having a bowel movement. Her last colonoscopy, performed 2 years ago, was unremarkable.

PMH

Hypothyroidism

Diabetes mellitus type 2

Hypertension

Dyslipidemia

Osteoarthritis

FH
Her mother is in her 80s and is healthy. Her father died in his 60s from heart disease. She has three
brothers and three sisters; one brother has type 2 diabetes. She has two sons who are healthy.

SH

She is married and works as a social worker. She quit smoking >20 years ago. She does not drink alcohol
and does not use illicit drugs.

ROS

(+) For constipation, lower abdominal fullness, N/V, right knee pain, (−) for SOB, CP, or fever/chills.

Meds

Diltiazem CR 240 mg PO daily

Chlorthalidone 25 mg PO daily

Levothyroxine 50 mcg PO daily

Metformin 1000 mg PO twice daily

Simvastatin 20 mg PO at bedtime

Multivitamin one tablet PO daily

Warfarin 5 mg daily × 5 weeks for VTE prophylaxis as directed by Anticoagulation Clinic

Oxycodone/acetaminophen 5 mg/325 mg one to two tablets Q 4–6 hours PRN

All

NKDA

Physical Examination

 Gen
Pleasant woman in distress because of abdominal discomfort; is visibly uncomfortable and
holding her stomach during the visit; appears tired
 VS
BP 122/60, P 57, RR 16, T 36.2°C; Wt 112.4 kg, Ht 5′5″; waist circumference 37 in; pain rated 5
on scale of 1–10
 Skin Normal skin turgor and color
 HEENT PERRLA and EOM full without nystagmus; no scleral icterus; oral mucosa moist; no
ulcerations noted
 Neck/Lymph
Nodes Supple, no lymphadenopathy or JVD; no thyromegaly or bruits
 CV
Regular, S1 and S2 without murmur
 Lungs
Normal breath sounds; no crackles or wheezes
 Abd
 Soft, obese, tender; decreased bowel sounds; stool palpable on left side
 Rectal
Stool present in rectal vault; no masses felt; tone fair; push strength fair; nontender
 MS/Ext S/P
right TKA; surgical wound healing appropriately; no redness, swelling, exudation; range of
motion within normal limits
 Neuro
A & O × 3; CNs II–XII symmetric and intact; DTRs 2+

Labs

Assessment

Constipation with fecal impaction; secondary symptoms of abdominal discomfort, nausea, and vomiting;
etiology likely drug-induced.

Plan

Obtain abdominal x-ray and CT scan to rule out other potential causes of constipation; perform
disimpaction.

Clinical Course

A plain x-ray of the abdomen showed gas-dilated loops in the colon. An abdominal CT scan was then
performed and showed a large amount of stool in the colon and rectal vault. Disimpaction was
successfully performed with no complications. A follow-up PEG-based bowel preparation was successful
in clearing bowel and relieving the patient’s abdominal pain. An appropriate medication regimen was
recommended to maintain regular bowel function over the next 2 weeks while she continues her opioid
therapy.

QUESTIONS

Identification

1.a. Develop a list of the potential therapy problems in this patient other than those related to her
constipation.

1.b. What signs or symptoms are indicative of constipation in this patient?

1.c. What are some of the possible nonpharmacologic contributors to her constipation?

1.d. What are some of the possible pharmacologic contributors to constipation in this patient?
1.e. What information should be obtained from a patient who presents with a chief complaint of
constipation?

Desired Outcome

2. What are the goals of pharmacotherapy in treating constipation?

Therapeutic Alternatives

3.a. What are some nonpharmacologic steps useful in treating constipation?

3.b. What are the pharmacologic options for the treatment of constipation?

3.c. Is this patient’s current regimen for hypertension appropriate? If not, what recommendations can
you make to optimize this regimen?

Optimal Plan

4. After nonpharmacologic measures have been attempted, what would be the most appropriate choice
of drug therapy for her, including dose and schedule? Provide the rationale for your answer.

Outcome Evaluation

5.a. How would you monitor this patient to ensure that your pharmacotherapeutic goals have been
achieved? How would you follow up with her to ensure resolution of the constipation?

Clinical Course

The recommendations you made were implemented, and Ms Reynolds returns to your clinic 1 month
later. She reports that the drug therapy you recommended resulted in regular bowel function
throughout the last 2 weeks of her opioid therapy. She does report, however, that her orthopedic
physicians have now recommended TKA on the opposite leg. She says that after the last episode with
constipation, she just does not think she wants to go through with it.

5.b. You reassure the patient that this problem can be prevented with her next surgery and that you will
discuss options with her physicians. What regimen would you recommend for preventing opioid-induced
constipation in this patient if she chooses to go through with the second TKA procedure?

Patient Education

6.a. What education would you provide to this patient who has concerns about recurrence of drug-
induced constipation?

6.b. What education would you provide to this patient regarding her concerns about laxative addiction?
6.c. When instructing this patient on using a stimulant laxative, what information should you convey to
ensure appropriate use of this product?

SELF-STUDY ASSIGNMENTS

1. Suggest pharmacotherapeutic options for the treatment of opioidinduced constipation in a pediatric

CLINICAL PEARL

When a patient presents with constipation, obtain a detailed medication history, because medications
commonly cause constipation. Management of medication-related constipation may include
discontinuation of the offending agent with initiation of an appropriate alternative or initiation of a
medication designed to address medication-related constipation. Failure to recognize medications as
contributors to constipation may lead to inappropriate treatment and inadequate relief of constipation
symptoms.