Tracey: the normal frequency of bowel movements is from three times
per day to three times per week.
What, like, how do you even answer that?
That's like saying, it's either one or a million it's
somewhere in there, that's nuts.
I mean, How do you know if someone's constipated based on that?
Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine,
where urgent care meets evidence.
I'm Joe Toscano, senior research editor for Emergency Medicine Practice,
and a member of the evidence-based Urgent Care editorial board.
Tracey: Hi there, and I'm Tracy Davidoff.
I'm editor in chief of Evidence-Based Urgent Care, and we're practicing
urgent care physicians with years of experience, probably too many years
of experience, on the front lines.
And for us, diagnosis is detective work and the clues are in the history,
the exam, and of course the evidence.
That thrill of solving the patient's puzzle is really
what keeps us coming back.
Joe: Each month we unpack the latest issue of evidence-based urgent care tackling
common chief complaints from presentation.
Through diagnosis to disposition, we highlight the best evidence, the key
takeaways, and the clinical pearls.
Tracey: And by the end of every episode, you'll have sharper skills, deeper
knowledge, and more sound strategies that you can use on your very next shift.
So let's dive in.
The evidence starts now.
And remember, you can always find more at www.ebmedicine.net.
Joe: Hi everybody.
Tracey: Good evening, good morning, good afternoon, or whatever it is
that you're doing right about now.
Thank you so much for joining us.
We are gonna talk today about poop.
Yes, we are gonna talk about poop today.
I know it's gonna be boring.
We're gonna try to make it as exciting as possible.
This month's episode is urgent Care Evaluation and Management of Constipation.
Believe it or not this was an update from an emergency medicine
episode and, Dr. Joseph Toscano.
Yay.
Dr. Toscano, my co-host was the lucky person who got to
update the article about poop.
Or the lack thereof.
Joe: There you go.
Tracey: So thank you so much for Joe for taking that on so that I didn't have to.
So Joe did that.
And then we had our peer reviewer with Sean McNeely.
Thank you so much for reading about.
Poop.
All right.
So we're gonna do this.
I'm gonna ask the questions and Joe is gonna give us the answers.
And we're gonna talk a little bit about this.
One of the things that, you know, I found that was interesting in
my research of this is that, well, actually, I'm not finding it fascinating,
and I'm not surprised at all.
People really shy away from this because they really hate managing constipation.
They hate talking about it.
They hate people showing them pictures on the phone of their poop.
They hate the vague abdominal pain, and I think I'm constipated, which
has so many different meanings for so many different people.
Should we be reframing that how we think about constipation and how we think
talking about bowel habits GI guys are good at it, but we see a lot of it too.
Why is it important, Joe, to be good at diagnosing and treating constipation?
Joe: Yeah.
You know, for a long time I used to think that, I used to
think, going to the bathroom's biology, it's not a medical thing.
Tracey: Yeah, right.
Joe: it's something your mom talks to you about, your grandmom talks to you about,
and you could talk to anybody and they'll tell you what they do for constipation.
It's like, why is this person coming to the urgent care?
Why is this person coming to the ER with constipation?
My God.
Tracey: Eye roll.
Joe: Yeah, I know, but you have to lean into it because they come and
you gotta do something about it.
And it's important because there are some complications of constipation that we have
to be aware of and there's some mimics and like it or not, because these patients
do come in, we have to, and this is not scientific, but it's just practical.
And it kind of emerges from the branch points in the clinical pathway.
It's not an initial three-pronged decision, but in the end we need to be
able to put patients into one of three categories as far as constipation goes.
There's that patient where they think constipation it's part of their chief
complaint, let's say, but there's something a lot more going on.
And somewhere during your h and p you start to get worried that
it's just not simple constipation.
There may be red flag symptoms or risk factors, multiple prior surgeries or bowel
obstructions, let's say, or exam findings.
And those patients are gonna be among the few ones in the ones that we see.
But, you know, those patients are gonna go right to the ED.
It's not gonna be, here's a laxative and then go home.
Then, at the other end of the spectrum and, these are the ones I tend to
see a little bit more in urgent care in the ED They're the people who are
concerned 'cause they've had decrease in the frequency of their stool, but
they're not in any really distress.
You talk to them about things, they tell you that the stool's slowing down.
They might have a little bit of gassiness or some distension, let's say, but
no real abdominal pain or bleeding.
And they may not have had that before and you are the one that's initially
educating 'em because their mom and their grandma didn't do that.
So a pretty straightforward approach for them.
And usually, with a history and a belly exam that's benign, we need to be
prepared for some recommendations about the stepwise use of stool, softeners,
laxative, those kinds of things.
If they haven't done that already, take them through.
And then there's everything in between.
And that's where we gotta put our thinking caps on.
There's a complaint of constipation, at least it may be
constipation plus something else.
But there's enough discomfort that it's not sort of, Hey, here, just
get some polyethylene glycol and follow the package instructions.
We need to really sort through and make sure that they don't have a complication
or a mimic, and that's where you're gonna be asking a lot more questions.
Doing a more in-depth exam and doing that, rectal exam that we all love to do.
Tracey: Yeah, I mean, I agree with you.
You know, a Lot of people just want some guidance and I think
it's sort of challenging trying to figure out who those people are that
need a little more than just, go.
To the laxative aisle and pick out A, B and C.
It's funny 'cause I find a fair amount of people that have
never tried one or two things.
They either have tried everything that's in the GI aisle or they've
tried absolutely nothing because they really didn't know where to start.
There's kind of like no happy medium.
It's either all Or Nothing which I think is pretty funny.
Joe: Yeah.
That's where education kind of Comes in, you know?
Tracey: And the other thing that I find a fair amount of is there's
a lot of clinicians out there that, are happy to hang their hat
on constipation as a diagnosis.
But The problem is there's a lot of those mimics, or a lot of things that
are even not related to constipation, that have constipation as a symptom.
I kind of urge people to, don't think of constipation as a diagnosis.
Think of it as a symptom of something else.
And once you've ruled out that there's nothing else going on there that you're
really concerned about, then you can hang your hat on constipation and treat that.
But then I also always give them the warning.
You know, This may be constipation, like I said, it's a sign of other things.
So if X, Y, and Z happens, please make sure that you Follow up in
case something bad happens, right?
So are there any myths that you busted when reviewing and rewriting this article?
Kind of things that we've been thinking about or doing for years
that are really just wrong and don't really have a benefit.
Joe: Yeah.
I think there are a few we, alluded to one of 'em and what we've already
talked about, and that is that constipation is always benign and
constipation is always constipation.
There are important mimics that can lead to decreased bowel movements like.
Obstruction some type of GI infections, diverticulitis, that kind of thing.
But even if it's just constipation, there are some complications
of it, like stercoral colitis
, Or a full on, you know, fecal impaction that's not gonna get
better with just a laxative.
And we need to evaluate the patient for those and reliably exclude them.
You can't really just take the patient's complaint of constipation at face
value unless once you ask them more questions, it seems like their only
complaint is a little bit of a decrease in their stool frequency and they're
not otherwise having any problems.
One of the other myths is the usefulness of x-rays.
It's kind of intuitive, Hey, I should see a bunch of stool down there that should
help me confirm the diagnosis and rule out other things like a bowel obstruction.
But the fact of the matter is that they're not sensitive enough to
rule out those important mimics.
You may, if the patient has a bowel obstruction, see a bowel obstruction,
but you can't really rule it out with x-rays that are not showing that A
lot of times they're non-specific.
The other side of that is that they don't always show constipation when
the diagnosis may be constipation.
There are a couple of cited studies in the article where, and particularly
in pediatric patients, x-rays are done very frequently, particularly in
the ED, they don't affect management.
That the x-ray is done and there may or may not be constipation,
but if it seems like history and exam suggests constipation,
that's what the diagnosis was.
And a lot of the ED physicians that were asked about why they got the
X-rays, it was to get parental buy-in and is that a reason to do an x-ray?
Tracey: That's crazy.
You're radiating some poor kid just to buy in with the parents.
That's, you know, I, I urge against that.
Joe: Yeah, exactly.
X-rays were the main thing that were available to us for so long and it's
really, when you think about it, it's like you're looking inside the body, right?
But you're really not looking inside the body.
You're looking at shadows as you cast x-rays through the body and
the real sensitivity for a lot of things is so poor we just shouldn't
be doing 'em automatically.
And then, maybe the third myth is the usefulness of docusate or we try to avoid
brand names, but colace basically, right?
This is probably in most people's minds, the stool softener that's the most
commonly recommended, but most high quality studies show that it doesn't
really do anything and there's certainly a lot of other better alternatives.
So it probably should come off our list of recommendations for patients.
It doesn't really soften the stool.
It doesn't have a laxative effect.
It's like not taking anything.
So
Tracey: I remember writing years of admitting orders for
outta the ED or as a resident.
You know, That's always on there with the acetaminophen and the antacid . And
you gotta add the stool softener.
'cause they're a hospitalized patient in bed.
They're gonna get constipated, So make sure you give 'em the docusate.
No.
Doesn't work anymore.
Joe: They may get constipated but the docusate's not gonna help.
Hey, it works for ear wax though, it's a good, nice uh, cerumenolytic
Tracey: Actually, there's also some studies that say it works pretty
decent if you mix it into the enema.
but orally not so much.
Joe: Yeah.
that little gel cap kind of thing.
Yeah.
Tracey: talking about the myths, the one thing that kind of freaked
me out was the normal frequency of bowel movements is from three times
per day to three times per week.
What, like, how do you even answer that?
That's like saying, it's either one or a million it's
somewhere in there, that's nuts.
I mean, How do you know if someone's constipated based on that?
I remember getting it drilled into my head.
You have to have a bowel movement every day.
A normal bowel movement's once a day, from mom and auntie and
grandma, did you have your BM today?
So, not necessarily, true.
You know, everybody has their own normal, I guess that's really the point.
And, asking if somebody's constipated and they say yes you, gotta ask, well,
on a good day when you're normal, what is your frequency of bowel movements?
And that's how you decide if somebody's actually constipated or not.
Because I know a lot of people Three times per week that would be agony for them.
And a lot of people.
If they don't go every single day.
they're Yeah.
they're in trouble.
So you really have to flush that out when you take your history.
Joe: Yeah.
Well, I'll clear up a little bit of that if I can.
There's the study in there where they developed the Bristol stool form scale.
That was over 30 years ago in the United Kingdom.
And you just gotta imagine diets were different.
Bangers and mash and fish and chips and stuff.
And so who knows what a normal stool frequency is in
another country 30 years ago.
Tracey: Yeah.
Joe: But the three per day to three per week actually came from a study that
was published in 2018, so relatively recently, was adults in the US.
Most of our patients are from the US.
Most of our listeners are from the US and it was NHANES data from 2009 to 2010.
So a bit longer ago, but rather than using kind of the usual statistics, what
they did was found a subset of patients almost 5,000 of them, 4,775, who felt that
their stool frequency was quote, normal.
And then they asked them how frequently they went, and it turned out that 95.9%
of them went three to 21 times a week.
So that's what they said.
This, it's not really the statistics of finding a mean, and then two
standard deviations is quote normal.
And there's not a lot of other data.
Interestingly enough, this study hasn't been cited by other studies.
You can search stool frequency and there's not that statistical
kind of basis as what's average.
And then what's two standard deviations?
We just don't have the information.
So this is the best data we have, but not really, like statistically valid.
96% of people who feel that their bowel movements are normal go
between three and 21 times a week.
like you said, when it's less than your own normal and you
begin to feel uncomfortable that's the diagnosis of constipation,
Tracey: Yep.
All right, so let's go over some red flags.
Most constipation, treat and treat.
You know, You get a history, their belly's benign, no big deal.
You give 'em some recommendations and bye-bye.
What would make you think otherwise?
And what are the disease processes or those mimics that you were talking about
and which are the most serious of those?
Joe: Yeah, well, you know, table four in the article has a nice sort of
list of the, you know, as you're going through and asking your questions
associated with the chief complaint.
And then a review of systems like weight loss and cachexia and those kinds of
things, and even family history of colon cancer can have a bearing, maybe not
on your acute diagnosis but maybe other recommendations you're gonna make on
the patient if they don't get better.
You think about the fact that simple dehydration can slow somebody's stool
down too, it's like, well, what if they're ill and they have dehydration
and have a decrease in their bowel movements, as a result of that.
So some of the red flag symptoms are fever.
Nausea, vomiting, jaundice.
Jaundice is bad no matter what.
Bloody bowel movements or anemia on a CBC, I would say, severe rectal pain.
And obviously, peritoneal signs or significant tenderness of
a patient on abdominal exam.
when you think that a lot of illnesses could be reflected
in decreased bowel movements.
You gotta step back and ask more questions.
Could somebody with pneumonia have constipation?
Well, yeah.
And if you didn't ask about those symptoms or they didn't
volunteer 'em, you might miss that.
I think if you think about just the belly obstruction is probably the main thing
that's gonna decrease somebody's bowel movements and be one of those mimics
that's gonna be important not to miss, but also stuff like diverticulitis.
A hernia causing an obstruction could uh, hopefully people would have pain
or something else that would lead you down that diagnostic pathway.
But sometimes you have to ask if a person's really fixated
on the decreased frequency of stool, that may be all they say.
And if you don't ask 'em any more questions or examine 'em really
closely, you're gonna miss those things.
Tracey: so maybe you know, fever, pain.
Bleeding.
vomiting.
But you know, I mean, There can certainly be bleeding just from
straining on hard stool, you know, the old rectal fissure or hemorrhoid.
But, if it's truly bloody stool or, truly blood mixed in with the stool, that's
way more serious than I saw a drops of blood on the toilet paper when I wiped.
Joe: Heavy, heavy, heavy bleeding.
And you know, that's sometimes hard to quantitate, but if it's
almost like, Hey, that should be the person's chief complaint,
should be their chief complaint.
Tracey: Yeah.
well, sometimes it is, you know, and then you ask a few more questions
with that and they're like, oh Yeah.
I've been pooping rabbit poo for three days, and now my belly's distended,
And that's why my hiney's bleeding.
So yeah, you gotta flush that out.
Joe: What about vital sign abnormalities, tachycardia, hypotension,
you know, lowest soft blood pressure, tachypnea.
Those things are gonna tell you, you got a sick patient in any realm.
Tracey: Hey, I do it with every single episode.
So I'll just mention the vital signs.
Again, you know, vital signs are so stinking important.
you gotta look at those and you gotta explain 'em, you know, so if The
person's tachycardic, hypotensive, obviously this is badness when you're
talking about constipation, literally for every patient you see, if you
see all of those, you really need to explain your abnormal vitals,
and that's.
One, you're gonna prevent that bounce back.
You're gonna catch that more serious patient.
And God forbid you should get sued, you know, if you miss those vitals
and that's you're done, literally.
Joe: It's, an objective measure that's sitting right there in the chart.
You can always argue about, well, how tender was the patient's abdomen, but
a heart rate of 1 22, it's right there.
Tracey: you got it.
You got it.
You mentioned a few things that I think people will definitely
not want to do in urgent care.
One of the things was rectal exams on everyone with constipation.
Do we really need to do that?
Is that really necessary?
Joe: No, I don't think so.
you look in the clinical pathway, we altered the clinical pathway a little bit.
On this from the ER issue to the urgent care issue.
And if there's a concern about fecal impaction or if there's
bleeding or a lot of rectal pain, then you gotta do the exam.
But if it's that, second category of patient where they're really not in any
discomfort, they don't have any bleeding and they're just telling you, you know,
my my bowel movements are starting to slow down, and I'm a little bit bloated
and I'm concerned, I would say that person doesn't need a rectal exam.
And I would say somebody who's really sick and has peritoneal signs, don't
worry about the rectal exam, if somebody's gonna pursue that at some point, but
you already made your determination that the patient needs to go to the
ED, why put them through a rectal exam?
Really it's third group of patients where you're sorting and sifting and
they're a little bit uncomfortable and maybe they had a little bit of
blood on the toilet paper when you gotta kind of look down there and
then also see if they're impacted.
Also fissures, you know, that can be an important finding.
It could be the result of constipation, hard stool passing through the anus.
But it can also cause constipation.
Sometimes people
have so much pain if they have a fissure for some other reason and then they
have discomfort with having a bowel movement, they'll actually not go.
It could become constipated or develop a fecal impaction.
'cause they're just, it's too uncomfortable to go and
you gotta manage the fissure.
And management of the fissure will help 'em quite a bit and it all
contributes to the pain that makes it very difficult to get any farther.
Tracey: Let's talk about enemas and disimpaction Uh, There is a
section about that in the article about doing that in urgent care.
Not really sure we can or should be doing those in urgent care.
Have you ever done 'em in urgent care?
I actually have I, used to work at an urgent care where it was
run by a discovered or founded by an ED doc, and he was firm into
keeping those people outta the ED.
'cause my guess is he didn't wanna see 'em in the ED.
So he went out and he bought the little bedside commodes and he
bought the, soap suds enemas.
And he made the poor nurses do enemas on, we had a lot of elderly patients do these
in the clinic, stink up the whole place.
It was awful.
No patients even wanted to be in there when that happened, that
was awkward, , but, it was a service we provided to some people.
I'm not sure every urgent care is gonna wanna do that.
What's your take?
Joe: Yeah, I think you just have to decide whether you have the resources to
do that and whether the other, clientele are gonna be maybe bothered by it.
It's not that you can't but you may decide that it's just not appropriate
for your venue but there's nothing about it that, you couldn't do.
it's just sort of messy and difficult to think about and also if you're
gonna do soap suds, I don't know if I would do soap suds just 'cause
of the volume that's involved.
But, you know, like A fleet enema or 133 ML enema, you can administer
that in urgent care and make sure the patient's close to the
bathroom or have a bedside commode.
I do see some self selection.
Seems like most of the patients that need that sort of thing do end up in the ED
whether they come over from urgent care or just sort of self refer themselves there.
And it's a kind of a group of patients who don't necessarily need that,
who tend to come to urgent care, so you can help them with education
more and ruling out the bad stuff.
And it's never a fun thing, but being prepared, makes all the difference.
If you're gonna do it, you gotta make sure, it's almost like PPE basically.
You should have an impervious gown.
You want to have eye protection, double glove, lots of lube.
And I wear an N95 'cause this just.
I don't know.
There's something about the smell of that, you can even put some coffee
grounds in it, N95 it, it can be kind of nauseating, the whole kind of process.
I have found, I'll say it, it's uncomfortable for the patient.
I have colleagues who don't stop until they like take 50% of the stool ball out.
But I find sometimes just in the process of removing a little bit and
softening it up, you can follow it with an enema and, it almost always works.
It's just priming the pump almost
I mean, If you have somebody with a huge stool ball, it's gonna be
hard to do no matter what anyway.
more than anything else, you're sort of softening it up, removing a little bit.
Even, I'll use sometimes lidocaine gel and it kind of numbs up the,
distal rectum in the anus a little bit so it's easier to pass stool.
It's almost like removing a foreign body from an ear though,
because it's hard to get above it.
How do you get above this ball and pull it down?
You're digging at it.
They have these plastic corkscrew things that I've never used but I've
seen advertised, which does kind of make some sense if you can screw
it into the stool ball and sort of maybe deliver it like a baby.
Tracey: like a bottle of wine,
Joe: something like that
Tracey: the bottle of wine.
Joe: It's just it.
I think it's just a difficult thing and it's one of those things
where if you don't feel like you're set up to do, it takes time too.
Which is another thing for urgent care.
It's a procedure almost.
Not only to do that, but then to administer the enema and
wait for it to have some effect.
And then dealing with the aftermath.
So I wouldn't blame anybody for not wanting to do it in urgent care and,
sending those people onto the ED, but , it's technically not difficult.
So it could be done in urgent care.
Tracey: Yeah.
I think the average patients with constipation that we see in urgent
care are gonna be in the mild to moderate category, and we're not
gonna need to prove that they're fixed before we discharge them.
And I'm sure they would be way more comfortable pooping in the,
comfort of their own home rather than doing it in some bathroom.
And that's the other thing.
I mean, uh, We only have one toilet in the back with the patients.
If it's, tied up with somebody who's evacuating what do we
do for the urinalysis And the little kids that have to pee?
that could definitely be a problem.
So that might be a, a limiting factor too.
Joe: it's a logistical, thing.
I think more than a, a risky thing, let's say.
Tracey: Yeah.
Yeah.
So I wanna talk about the dangers of diagnosing abdominal pain as constipation.
I mentioned that a little bit, above.
I, I never feel comfortable doing that.
Most of the patients that I diagnose with constipation I better be pretty
clear that they, you know, maybe they have some abdominal discomfort
or some distension, but not true abdominal pain because I think.
Even if you get that x-ray and you see , that stool on there or they
tell you they're constipated or even if you feel it with your finger,
like I said, constipation can be a symptom of some other disease process.
How do you know when it's safe to call it just constipation, we talked
about the red flags there, but let's just add a little bit more on that.
Joe: Yeah.
Yeah.
Well, if you think about anything in the abdomen even like pancreatitis,
which has nothing to do with the intestine or aaa, that's enlarging
those things can cause an ileus.
That can decrease a person's stool frequency.
And if the person is focused on the decreased stool frequency,
you can miss those other things.
And most of the time those are gonna be painful.
And that's where the abdominal pain comes in.
I think the basis of your question,
It's important to get at that in your history, what is the chief complaint?
Is it only decreased bowel movements or decreased bowel movements plus
belly pain, then you gotta ask all the belly pain questions, really.
Or when you palpate the abdomen and there's anything more than mild
tenderness or gassiness almost mild distension then, you really gotta ask
a lot more questions and think about doing more in terms of your exam.
If again, what's the patient's chief complaint and then as I'm
sorting through in my mind, what should be the chief complaint?
We've talked about that with the bleeding.
It's like you're concerned about the constipation, but your abdomen
is really tender and you have a lot of pain, so reframing what you're
concerned about after that chief complaint is important and something
else may rise to be more important.
Things like vomiting tend to indicate that ileus or a GI infection or
obstruction, fever of course.
And then, if there's anything more than minimal pain, then you
really gotta diagnose the pain.
As well as the decreased stool frequency, I think.
And to say that it's just constipation, I think you really
have to do something about it.
And that's where you're probably talking about an enema, having the
patient have a bowel movement and then feel back to normal And like you
said, sometimes it's safe to do that in the comfort of their own home.
But that's Where you have to advise them and say, look, you got a
little bit of abdominal discomfort.
Your stool's decreased.
It doesn't look like anything else going based on your answers
to these questions and your exam.
So do something to stimulate your bowels.
And if you go and you feel back to normal, you're done.
But if you don't feel back to normal or these other symptoms
develop, then you need to be concerned about these other things.
I remember, geez, probably within the past year or so, a young
guy came in with constipation.
That was his, chief complaint and it turned out he did have some pain, but
he also had some decreased bone wounds.
Never been constipated before.
Had no reason to be constipated.
Had some tenderness across his lower abdomen, but did not want any tests.
Said, look, I talked to my mom.
She said, I'm just constipated.
I was like, well, I'm concerned you have this or that.
And he said, no I'm constipated.
What do I do?
I said, what did your mom tell you to do anyway?
I, had him get some polyethylene glycol.
I think that tends to work pretty well.
I see most of our GI people and our surgeons recommend that.
And sure enough, two days later, he came back with right lower quadrant pain and
had appendicitis, which probably was present right from the start, but he
himself had to be convinced about that.
He followed the precautions too and came back.
And it wasn't a perforated API or anything like that, but I documented
the heck out of that, that, this patient needs other tests but doesn't want them.
And also the, discharge instructions I think were important for him to know.
This isn't simple constipation because you went to the bathroom
and you didn't feel any better.
Tracey: Right, right.
Joe: Yeah.
Tracey: Exactly.
Yeah.
All right.
So let's bottom line treatment real quick.
Does one size fit all?
Should you just have a go-to that you give to everybody?
And then what do you do with the patient that says, I've tried everything
in the store and nothing's working.
What do you think?
Joe: Oh my gosh.
It's hard to deal with somebody who's done everything already.
Anyway, but there are differences in the potency of the different
things that are available.
It's always gonna be the case that some things work better
for some people than others, and that, that's just kind of biology.
I think, for some people, acetaminophen works better for their headache than
Ibuprofen does, and then for somebody else, that's gonna be the opposite.
For a lot of those basic things, just the way it is.
But we do know that in general for all comers stuff like fiber and stool
softeners are the lowest intensity, the lowest level, and not super effective
if somebody's already constipated, they're more like preventative things.
Increasing fiber or, taking a stool softener might help if
somebody's in the early stages.
There are a variety of stimulant laxatives that are the next step up,
the next more aggressive treatment and there are several to choose from.
And you can pick your favorite one as that second line agent or,
give the patient some options.
They can be taken something like, ducalax can be taken from above or below.
And I guess you have to be a little bit careful sometimes about doing
something from above if somebody's already constipated because it,
can be uncomfortable as it's starting to churn its way through.
or particularly if it's a strong stimulant has a strong stimulant effect, it might
maybe conceptually be a little bit better to put it down below and stimulate.
Like, uh, do it in a suppository form.
I think, in the issue, the data somewhat supports this, that polyethylene glycol,
which comes in a variety of generic forms, but it's basically MiraLax, right?
Is probably the most useful.
And I think when you think about this I, I didn't talk about it in the issue so much,
but it is what's used in a bowel prep.
And you can do it one of two ways.
The old bowel prep was you take a gallon of fluid, and about 400 grams
of P E G . so the usual daily dose of glycol is 17 grams a cap full mixed
in whatever beverage you want to use, and that'll help keep you regular.
If you don't take it every day and you get constipated, it
can help you get unconstipated.
But here's A medication with a range of dosing from 17 grams to 400 grams
, Tracey: Oh my gosh.
Joe: just basically keep.
Take a dose, take another dose, and you can do that either gently, progressively,
or, I wouldn't recommend it that I actually have had GI doctors recommend
to me when I call them about a really constipated patient, having them do
a gallon of go lightly, basically, or a gallon of polyethylene glycol just
gradually over a longer period of time.
But the new bowel preps, cram a lot of polyethylene glycol into two doses.
Basically, you take one.
Uh, My, my colonoscopy, gosh, I don't know.
A couple years ago, and it was two doses of polyethylene glycol, like a big dose
followed by a little dose or a little dose followed by a big dose, I think.
And it just, it can really, I wasn't constipated, but it
can really clean you out..
I think there's a lot of benefit in that and having people step
up the amount that they use.
You have to maintain your fluid intake too with that though.
And something in that range.
So that's your answer to everything in the store.
If the person has taken, everything in the store, tell 'em to take
there are max doses for the stimulant, laxatives and, magnesium
citrate, other things like that.
But polyethylene glycol, you can really kind of increase over time and it could
help there are prescription medicines That are available, but they're mostly
for chronic constipation, there's not a lot of evidence that they help
if somebody's acutely constipated.
If somebody has multiple bouts of constipation that you would call
chronic constipation, that's a medicine that might help them not
get constipated as frequently.
We don't really prescribe them in urgent care.
I mentioned 'em in the issue because it's important for us to be familiar with them.
I am seeing more primary care doctors prescribe those, though they used to
be just in the realm of GI doctors.
But now I see, people on them and say, oh, who's your GI doctor?
Oh, I don't have a GI doctor.
My regular, my primary care doctor prescribed it for me.
And then finally, for opioid induced constipation, methyl naltrexone works
really I haven't ever had to do that in urgent care, but that works really well.
I've done that in the ED often for people with opioid induced constipation.
Sometimes patients on hospice and other things like that where the constipation
is really uncomfortable for them and it actually works really well.
Tracey: My mother was a oncology nurse and she used to have people that were
on chronic narcotics all the time.
Joe: Yeah.
Tracey: She used to call severe constipation in a
cancer patient, obstipation,
obstinate, constipation.
But whenever I ever tell anybody else that word, nobody ever seems to have
ever heard of it before, but I always thought it was a cool thing to say,
Joe: Yeah.
Yeah,
Tracey: so, out of everything that you've discussed in the article,
was there anything that you found surprising or didn't really know
when you started that you thought, Hey, wow, I'm gonna remember that.
Joe: well, you know,
stercoral colitis.
I keep wanting, say stercical.
Anyway, I'm not really sure about this disease entity.
I included it in there because it is written about, it was part of the
initial emergency medicine issue.
But this is something I hadn't heard of in the first 20 years of practice.
And, you don't hear about it in urgent care, but sometimes a radiologist will
call it on CT and I would have to say getting on the phone with GI specialists
and surgeons and say, Hey, I have a patient here with fecal impaction and
stercoral colitis, They don't really care.
so it's not really maybe as bad as it could be.
So I guess have to say I don't know what to do with this diagnosis.
The issue, actually talks about sometimes using antibiotics and that it could be
if the patient's sick and they have fever and a leukocytosis and that kind of thing.
It could be from stercoral colitis, I guess.
Or you gotta be sure that there's nothing else going on also.
But I guess I'd have to say that's the thing that I still don't know about
Tracey: Yeah.
Joe: I didn't know about, and I still, I'm kind of unsure how to handle that.
I think you gotta call it and call in your specialists because it's not
something that I would dismiss, but
I'm still kind of Unsure what to do with that.
Tracey: Definitely.
Yeah.
One thing that I saw, I mean, it sounds ridiculous because this is such a, common
thought was the frequency of, bowel movements that are considered normal.
I mean, That was so surprising to me cause I know some people that
go very frequently and some people that, that go less frequently
. And I guess just putting it into words that normal is what is normal for
you and not necessarily, any specific number that you have to go every day,
like mom said, so I guess that was probably what was the most surprising
to me out of everything in the article.
Joe: Yeah.
The consistency of the stool is important too.
You know, is it soft or rabbit, turd small.
And that's where the Bristol stool scale can come in.
And so in addition to a decrease in frequency kind of a hardening and a
getting smaller of the stool is also something that can show that impending
constipation is around the corner.
Tracey: So if you're only going every few days, but the softness
of the stool is of normal for you, then, you're not constipated just
'cause you missed a few times.
If you're still going and it's still soft, it's not hard as a rock.
It's probably not constipation.
Some people are just so preoccupied with that, it's like, I didn't
go to the bathroom today.
Oh, okay.
Like, do you have any other symptoms?
Well, no, I didn't go this morning.
I'm like.
I dunno what to tell you,
All right.
Let's just talk about some bottom lines.
Like, the big one, we've said it a couple times, is don't just
diagnose constipation with x-rays.
That's really low sensitivity, specificity.
One of the things that I tell people when I'm teaching about this is that I
guarantee you, if we x-rayed a hundred asymptomatic patients, 50% of them would
look like they were constipated on x-ray and not really have any symptoms and
not really be constipated because it all depends on when you see the poo.
If I'm gonna x-ray somebody right before they have their morning bowel movement,
you're gonna see lots of poo in there.
But that doesn't mean they're constipated.
So really don't hang your hat on that one.
I think the radiologists have pretty much stopped calling
constipation on plain films.
Joe: Yep.
Tracey: I think we probably should too.
And, one of my other schticks is, you know, a lot of people will do a
flat plate to see if the patient's constipated, what you're really looking
for is not for stool volume, but for the complications of obstruction or dilated
loops or, the large width of the colon.
which you're really not gonna see on a flat plate.
So if you are gonna order an x-ray, you probably need to order the whole
series with a, upright or a lateral decubitus to really get the sense of that.
But, bottom line sensitivity for constipation on a plain film is not good.
So don't hang your hat on that again, we talked about ruling out other causes.
Constipation is a symptom, not really as a diagnosis.
Unless you've ruled out all those other things, you really shouldn't hang your
hat on that constipation diagnosis.
And then red flags.
We talked about those red flags and if, you start seeing 3, 4, 5 red flags
in one patient, that's your signal that, oh, we're in trouble here.
That patient's probably gonna need not a plain film, but a CAT scan
to figure out what's going on.
That's our bottom line.
Take home points then.
Anything else you wanna add?
Joe: Yeah, I'll tell you my, last most memorable constipation
chief complaint that didn't have constipation was a 54-year-old guy
who came in, in the ED, and he, it said chief complaint, constipation.
So I said, Hey, what's going on?
He goes, yeah I haven't gone in a couple days.
I usually go every day.
Okay.
Did anything lead up to it?
You know, All those questions, no red flags, and he had some
left lower quadrant discomfort Discomfort that was intermittent.
He said, not necessarily related to trying to go.
he said he tried a number of laxatives and a suppository and nothing came out.
And, he had a little, the tiniest bit of dysurea.
So no tenderness on exam even though he had this left lower quadrant pain.
Did a urinalysis and, he had like 25 to 50 red cells.
It wasn't gross hematuria.
And so I said, you know, this might be something urinary even a have
you ever had kidney stones before?
No.
and the rectal exam, he had no stool in the vault.
So I was like, well you're probably not going 'cause there's nothing there.
Obviously I can't tell what's farther up.
Anyway, ended up doing a a CT without contrast.
He had no stool anywhere in his colon anyway.
And he had a distal Ureteral stone.
So sometimes Decreased stool frequency could be coincidental.
Tracey: Yeah.
Joe: if the person isn't really thinking about the other symptoms,
they may just be focused on that.
So then it's not constipation if it's just coincidental,
Tracey: Right.
Joe: that patient brought home to me.
I mean, If he hadn't tried any laxatives and it didn't work, I probably would've
said, well, why don't you just try a laxative and come back if it doesn't work?
And the Interesting thing was he did not have very bad pain with the stone.
Tracey: Yeah.
Joe: And if he had severe pain, radiating to his flank again, that
would've been his chief complaint.
Tracey: Yeah.
Joe: but it's these kind of one-offs that can get us in trouble sometimes
if we don't ask all the questions.
And
it was that little bit of feeling like he had to remember.
I feel like I have to go, but not a lot's coming out.
And it's a little bit irritated on the urinary Side, so anyway.
Tracey: My weirdest one actually turned out to be shingles,
Joe: Oh.
Tracey: which, Yeah.
And it was a long time.
The lady had pain for like three weeks before she finally broke out in the rash.
It was crazy.
She came in with left lower quadrant abdominal fullness and I'm constipated,
so we really had no significant findings, nothing like that.
I treated her with some laxatives, but I said, you know, you don't get better.
She had a GI doctor for some other reason I think GERD or something.
I said, call your GI guy.
So she calls the GI guy 'cause she doesn't get better with the laxatives.
The GI guy, CAT scans her, she's got nothing.
He says, go see your GYN.
She goes to see your GYN.
Her GYN ultrasounds her.
She's got nothing.
She came back to me three times and on the third time I'm like, you know what?
Let's get you all the way undressed just to see if there's anything, damn.
Wasn't there a rash there?
And it, that was it.
And once her shingles was gone, her sensation of constipation went away.
So Yeah.
it can be anything, it really can be anything and you really have to be
diligent about trying to figure it out.
I mean, Granted, don't look for shingles if you have constipation,
but anything is possible, right?
Joe: Wow, that's wild.
Medicine is just so interesting.
Gosh.
Tracey: is.
It is.
All right so much for poo.
I think we're done with Poo.
Joe: Good.
Tracey: Yeah.
thank God.
Right.
Next up, just in time for summer, we're gonna be talking about some marine
injuries next, which is very interesting.
I found some cool pictures are gonna be in the issue of all kinds of things.
The gentleman who wrote it is very passionate about the subject and
there's some really cool stuff in there.
And then followed by weight loss meds, which, we didn't really talk about with
the constipation here, but weight loss meds, I'm seeing a lot more constipation
with the glp so we will talk about that a little bit more when we talk about weight
loss meds, so stay tuned for that one.
Joe: can be constipating.
Actually, there's a great table in the issue, so
Tracey: There is, you should go.
check it out.
Yep, exactly.
All right.
So thanks everybody for listening and happy.
February.
Yeah.
Happy Valentine's Day.
There we go.
Joe: That's right.
Tracey: I hope you're all doing something fun with your loved
ones and we will see you in March.
Joe: Thanks everyone.
Take care.
Tracey: Yep.
Thanks.
Take care.
Bye-bye.
Joe: Bye.
Tracey: I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net
and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.