Poop, part I

Ohhh emergency medicine...the good, the bad, the stinky

1) Why? It's all in the HPI!
- new drugs? (narcotics, anti-psychotics, anti-histamines)
- H/O constipation?
- weight loss? changes in stool (colon cancer!)
- passing gas?

2) What's going on in there? Rectal exam: gives you an oppotunity to rule-out other diseases (i.e. hemorrhoids, anal fissures, abscess).
 - can you palpate stool? masses?
 - soft? hard?

3) Further work-up?
- if you can find out the cause, this may not be necessary
- is the abdomen distended? vomiting? Think obstruction, get a KUB/Abdominal Series
- is constipation the only complaint? maybe you want to check the thyroid too
- concerns for 



Here are tools of the trade (funny how we have so many for constipation)
I) Fiber
   A) bran muffin, oatmeal, prunes, etc.

II) bulk forming laxative
   A) Psyllium (Metamucil®)
   B) wheat dextran (Benefiber®)

III) Stimulants (also known as anthraquinones)
   A) bisacodyl (Ducolax®)
   B) senna (Senokot®)

VI) stool softeners

   A) Docusate sodium (Enemeez®, Colace®)

   B) Glycerin suppository

V) Osmotic agents
   A) Lactulose (Enulose®)
   B) Sorbitol
   C) polyethylene glycol (GoLyteLy®, Miralax®) - 17g PO
   D) saline laxative
      i) Milk of Magnesium -15-30mL/day)
     ii) Magnesium Citrate -240mL PO once)

VI) enema
   A) Enemeez® (see above)
   B) mineral oil 
   C) soap suds (1500mL PR)
   D) phosphate (Fleets®)
  
Treatment:
Lifestyle: dear lord please drink water!!, eat some fiber (20-25g/day)!

Analgesics:
If they're on pain meds, please give them something extra... I think all the elderly should get something if on narcotics. In my surgery rotation is was routine to give Colace with Norco, but is that enough?  Dr. Orman from ercast.org notes that giving colace does nothing but leave soft stool in the colon. This does not help get the stool out, adding a stimulant like senna will improve gut motility.Unfortunately, this will add to the number of pills they will take. So I like the GoLYTELY combination:

POLYETHYLENE GLYCOL (17g/1 glass of water) PLUS SENNA (15mg/daily) WITH ALL NARCOTICS


next, the fecal disimpaction.....