A 38-year-old woman comes to the office due to constipation for the last 3-4 months. She has not had previous problems with bowel movements; however, she now spends 20-25 minutes having a bowel movement once every 3-4 days. The patient reports excessive straining; hard, pebble-like stools; incomplete evacuation; and intermittent digital disimpaction. She also has abdominal discomfort, bloating, and increased flatulence; all are relieved with bowel movements. Her appetite is good and her weight is stable.
The patient's other medical problems include anxiety disorder, vitiligo, migraine headaches, and fibromyalgia. She uses ibuprofen occasionally and takes no other medications. She underwent cognitive-behavioral therapy for anxiety and panic attacks approximately 3 years ago.
The patient does not use tobacco, alcohol, or illicit drugs. Her diet consists mainly of hamburgers, pizza, and fried foods. Family history is negative for colon cancer.
Vital signs are normal. Physical examination shows no abnormalities.
Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 38-year-old woman comes to the office due to constipation for the last 3-4 months.  She has not had previous problems with bowel movements; however, she now spends 20-25 minutes having a bowel movement once every 3-4 days.  The patient reports excessive straining; hard, pebble-like stools; incomplete evacuation; and intermittent digital disimpaction.  She also has abdominal discomfort, bloating, and increased flatulence; all are relieved with bowel movements.  Her appetite is good and her weight is stable.
The patient's other medical problems include anxiety disorder, vitiligo, migraine headaches, and fibromyalgia.  She uses ibuprofen occasionally and takes no other medications.  She underwent cognitive-behavioral therapy for anxiety and panic attacks approximately 3 years ago.
The patient does not use tobacco, alcohol, or illicit drugs.  Her diet consists mainly of hamburgers, pizza, and fried foods.  Family history is negative for colon cancer.
Vital signs are normal.  Physical examination shows no abnormalities.
Laboratory results are as follows:
 Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97fa_db02_853d_a73230a6fffc_MD0002_00 Chronic constipation is defined as >3 months of symptoms, including a combination of <3 bowel movements per week and >25% of bowel movements requiring straining (ie, lumpy and hard stools, sensation of incomplete evacuation, requirement of digital evacuation). Poor dietary habits or adverse medication effects are often responsible, but patients with alarm features (eg, prominent, unexplained change in bowel habits) should be evaluated for other secondary causes (eg, malignancy, hypothyroidism). This patient's mild hyponatremia and history of autoimmune disease (vitiligo) raise suspicion for hypothyroidism; macrocytic anemia is present in approximately 10% of hypothyroidism cases due to concomitant pernicious anemia. All patients with chronic constipation should undergo initial evaluation with detailed history, physical examination, and basic laboratory testing (eg, complete blood count, serum glucose, serum creatinine, electrolytes). Those with alarm features should undergo further evaluation, including additional laboratory testing (eg, TSH, serum calcium), abdominal imaging, and/or colonoscopy, as suggested by the history. In patients with no alarm features and an unremarkable initial laboratory evaluation, a therapeutic trial of medication adjustment and/or dietary fiber intake and lifestyle modification is appropriate before additional testing is performed (Choice D). (Choice B) Anorectal manometry assesses anal sphincter and pelvic floor function to assist in identifying neurologic causes of chronic constipation (eg, pelvic floor dyssynergia, Hirschsprung disease). This and other motility testing is typically reserved for patients who fail a trial of diet and lifestyle modification. (Choice C) Colonoscopy is indicated in patients with unexplained chronic constipation who have alarm features and have not recently undergone colonoscopy screening. However, TSH testing is less invasive and more clinically appropriate in this patient and should be performed first. (Choice E) Cognitive-behavioral therapy may have a role in management of patients with severe irritable bowel syndrome symptoms and psychiatric comorbidity. However, common secondary causes should be excluded before employing psychological treatments. Educational objective: The initial evaluation of patients with chronic constipation should include detailed history, physical examination, and basic laboratory testing. Those without alarm features can undergo a therapeutic trial of medication adjustment and/or dietary fiber intake and lifestyle modification. Those with alarm features should undergo further evaluation based on history, including additional laboratory testing (eg, TSH level), abdominal imaging, and colonoscopy. __________ References: Diagnostic approach to chronic constipation in adults. (http://www.ncbi.nlm.nih.gov/pubmed/21842777)

A 38-Year-Old Woman Comes to the Office Due to Constipation