Let's move to our next case.
A 78-year old man with Parkinson's disease and
dementia is brought to the emergency department
form his nursing home for complaints
of abdominal pain for the past day.
He has not passed a
bowel movement in a week.
He takes a hydrocodone-acetaminophen
for chronic back pain
Vitals are normal.
On exam, he grimaces to palpation
in the lower quadrants of his abdomen,
but there is no rebound or guarding.
A digital rectal exam notes
impacted stool in the rectum.
What is the best next step in management?
So let's point out some clues in this case.
He has a known neurologic
disorder that can impact stool transit.
In addition he is from a nursing home
which places him at high risk for constipation.
He does also have chronic opioid use
and on exam, he has fecal impaction.
So, let's talk about paralytic ileus.
This is a disruption in the
normal motility of the GI tract.
Some important risk factors
include a history of recent surgery,
any medications that can cause slow transit
such as opioids, or intraabdominal inflammation.
The clinical features of a paralytic ileus can be very
difficult to differentiate from a small bowel obstruction.
because patients also presents with abdominal
distention, pain, nausea and vomiting and constipation.
On exam, they often will
have hypoactive bowel sounds.
As with SBO, the diagnosis is
often made with an abdominal x-ray.
Here you can see an example of an
abdominal x-ray from a patient with an ileus.
The common features on x-ray are
dilated bowel loops and air on the rectum.
Note here that you do not see those
air-fluid levels that we saw with the SBO.
So, that brings us to
this important question:
How do you tell the difference between a paralytic ileus
and an SBO since they have so many common features?
There are several things that we
can use to distinguish between the two.
With an SBO, the bowel sounds on exam will often
be hyperactive or completely absent.
They may also have peritoneal signs on exam.
And on imaging, on x-ray you will see
dilated bowel loops and air-fluid levels.
On the other hand in a paralytic ileus, you often have
hypoactive bowel sounds but they may also be absent.
It is very uncommon to have
peritoneal signs with an ileus
and on imaging you will see those dilated
bowel loops but you will not see air-fluid levels
and because patients are still able
to pass gas throughout the colon,
they will have air in the rectum.
So the treatment of constipation
depends on several different factors.
First, we can recommend lifestyle and dietary changes
including increasing fiber intake and physical activity.
Pharmacologically, we can also offer fiber
supplements, osmotic laxatives or stimulants.
In very severe cases such as with fecal impaction
when stool becomes stuck or impacted in the rectum,
you may need to manually disimpact
those patients, or provide an enema for relief.
So that brings us to the common
medications we use for treating constipation.
We'll break it down by category.
The first category are fiber supplements,
examples include psyllium or methylcellulose.
and they work by increasing dietary fiber intake
to bulk up the stool and allow it to pass easily.
The next category is osmotic laxatives.
These are things like lactulose,
sorbitol, polyethylene glycol.
In principle, these are all poorly
absorbed or non-absorbed sugars
that then draw water into the colon via osmotic
pressure and allow for easier passage of stool.
Our next category are stimulant
laxatives, so things like senna or bisacodyl
and they work by stimulating the intestinal
motor activity to help push stool along.
Our last category is prosecretory agents.
Things like linaclotide, or lubiprostone.
These are medications often used in
the treatment of irritable bowel syndrome
and they work by increasing
the natural secretions of the colon.
So now that we've reviewed
that, let's return to our case.
Our 78-year old man with Parkinson's disease - so a
known neurologic disorder that can impact stool transit
plus he's from a nursing home
and he has chronic opioid use.
So all major risk factors for constipation.
He has fecal impaction on exam,
so the best next step in management
would be to perform a fecal
disimpaction or provide an enema.
Thank you very much for your attention.