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symptom.constipation.v1

Chronic constipation (outpatient symptom triage)

symptomchronicundifferentiatedadultgeriatricoutpatient
Start encounter →Print handoutPRODUCTION

Promoted SCAFFOLDED->INTEGRATED 2026-05-31. Decision surface = regimen_axes chronic_constipation_ladder (fiber/lifestyle -> osmotic -> stimulant -> secretagogue/prokinetic; PAMORA for OIC; biofeedback for dyssynergia), encoding the AGA/ACG ladder already described in this engine; no registry change. Added resolving workup.colorectal_screening (alarm-feature CRC eval). Evidence re-sourced + PubMed-verified via get_article_metadata: 37211380 (Gastroenterology 2023 AGA-ACG CIC guideline) + 27033126 (Nat Rev Gastroenterol Hepatol 2016); prior array was fabricated/placeholder. Laxative RxCUIs are candidate-floor and need RxNav revalidation before PRODUCTION. Phase C shard-3-neuro-sym wave-11 expansion (2026-05-15) — pattern-matches symptom.diarrhea.ed.v1 (wave-10), symptom.cough.ed.v1 (wave-10), symptom.nausea_vomiting.ed.v1 (wave-10), symptom.weakness.ed.v1 (c1c2bc96 wave-9). Engine scope: outpatient chronic constipation triage + cause stratification + stepwise pharmacologic ladder; covers normal-transit (IBS-C) / slow-transit / pelvic-floor dyssynergia / OIC / medication-induced / hypothyroid / hypercalcemia / DM2 autonomic neuropathy / structural-alarm / pediatric functional with encopresis / pregnancy / IBD-related / hospital constipation / fecal impaction. Bayesian linkage (LR+, LR−, pre-test priors by age/sex, alarm-feature thresholds, T_treat) lives in companion depth bundle _briefs/symptom.constipation.v1.depth.md. 4 sibling-differentiation rows cover key look-alikes (Crohn flare with proximal constipation / UC with proctitis / paradoxical overflow diarrhea / abdominal pain ED for SBO concerns). 7 severity triggers (≥7 per spec): alarm_features_new_onset_age_over_50 + fecal_impaction_with_overflow + sbo_perforation_strangulation_suspicion + opioid_induced_constipation_refractory + pelvic_floor_dyssynergia_outlet + severe_hypothyroidism_myxedema_features + hypercalcemia_severe_with_constipation. KEY SAFETY RULES: AVOID oral laxatives until impaction cleared (manual disimpaction first); deprescribe offending meds (anticholinergic / CCB / opioid taper if feasible / iron / antacid Al); biofeedback FIRST-LINE for pelvic-floor dyssynergia (not laxatives); PAMORA preserves central analgesia (does NOT cross BBB); colonoscopy MANDATORY for new-onset >50 or alarm features. Calculators wired (0): chronic outpatient phenotype rarely overlaps acute calculators. Bristol stool form / ROME IV — schema-blocked; ticketed in shard-3 state file. Panels wired: panel.cbc + panel.renal + panel.lft + panel.thyroid + panel.inflammation. Schema-blocked: workup.constipation / workup.anorectal_manometry / workup.colonoscopy_screening / calc.bristol_stool / calc.rome_iv_constipation — NOT in clinical-tools-registry; manual application in setting playbook required_assessments + ticketed in shard-3 state file. Regimen_axes intentionally empty — engine is triage-only. Stepwise pharmacologic ladder (lifestyle → PEG → lactulose/Mg → bisacodyl/senna → linaclotide / plecanatide / lubiprostone → prucalopride → PAMORA methylnaltrexone / naloxegol / naldemedine → manual disimpaction for impaction) lives in setting_playbooks.outpatient.drug_actions. Setting playbook: single `outpatient` per chronic engine spec — ED triage and inpatient management routed via escalation_triggers and disposition_criteria when needed (impaction failing outpatient, SBO concern, severe hypothyroidism, severe hypercalcemia). SCAFFOLDED status: no workup.constipation in clinical-tools-registry; PRODUCTION audit would fail. Will promote once registry entries land.

Entry points (15)

  • symptom
    Chronic <3 bowel movements/week + straining + lumpy/hard stools + abdominal pain/bloating relieved by defecation — primary normal-transit constipation / IBS-C (ROME IV); first-line PEG + lifestyle (Bharucha AGA 2013 PMID 28144963)
    primary_normal_transit_chronic_IBSC
  • symptom
    Severe refractory constipation + delayed colonic transit on radiopaque marker / scintigraphy — slow-transit constipation (colonic inertia); prosecretory (linaclotide / plecanatide / lubiprostone) or 5HT4 (prucalopride) per ACG (Vazquez 2021 PMID 31000341)
    slow_transit_constipation
  • symptom
    Constipation + impaired evacuation + paradoxical pelvic-floor contraction on balloon expulsion / anorectal manometry — pelvic-floor dyssynergia; BIOFEEDBACK first-line (not laxatives)
    pelvic_floor_dyssynergia
  • symptom
    Chronic opioid use + constipation refractory to first-line laxatives — opioid-induced constipation (OIC); PAMORA (methylnaltrexone 12 mg SC, naloxegol 12.5-25 mg PO, naldemedine 0.2 mg PO) per AGA (PMID 30094000)
    opioid_induced_constipation
  • symptom
    Constipation + offending medication (anticholinergic, CCB, opioid, iron, aluminum antacid, antipsychotic, TCA, ondansetron) — drug-induced; deprescribe / substitute
    medication_induced_constipation
  • symptom
    Constipation + cold intolerance + fatigue + weight gain + bradycardia + elevated TSH — hypothyroidism (severe → route endo.myxedema-coma.core.v1); levothyroxine + constipation typically resolves with replacement
    hypothyroid_constipation
  • symptom
    Constipation + bones-stones-groans-moans + Ca >12 — hypercalcemia (PTH-dependent vs malignancy); workup cause + IVF + bisphosphonate / denosumab / calcitonin / cinacalcet
    hypercalcemia_constipation
  • symptom
    Long-standing DM2 + constipation alternating with diarrhea + gastroparesis features — diabetic autonomic neuropathy; glycemic control + prokinetics + osmotic / stimulant
    dm2_autonomic_neuropathy_constipation
  • symptom
    New-onset constipation >50 + alarm features (rectal bleeding, anemia, weight loss, family hx CRC, nocturnal sx, sudden change in caliber) — route ED + colonoscopy STAT (CRC, stricture, volvulus, SBO concern)
    structural_obstruction_alarm_features
  • symptom
    Pediatric (≥1 yr) chronic constipation + retentive posturing + encopresis (paradoxical soiling) — functional constipation per NASPGHAN/ESPGHAN; PEG 1-1.5 g/kg/d disimpaction + maintenance + behavioral
    pediatric_functional_constipation_with_encopresis
  • symptom
    Pregnancy + constipation — physiologic (progesterone) + iron supplements; psyllium / PEG safe; AVOID stimulant laxatives long-term + AVOID castor oil (uterine stimulation)
    pregnancy_constipation
  • symptom
    Known IBD + proximal constipation (especially proctitis / distal UC) — route gi.crohns.core.v1 / gi.ulcerative-colitis.core.v1; address active disease; topical mesalamine + PEG
    ibd_related_constipation
  • symptom
    Hospitalized / postoperative / immobile / opioid-exposed inpatient + no BM >3 days — hospital constipation; bowel regimen (PEG + senna + bisacodyl PRN); rule out ileus / SBO
    hospital_constipation_immobile
  • symptom
    Severe constipation + DRE confirms hard stool in rectum ± paradoxical overflow diarrhea — fecal impaction; manual disimpaction + enemas (saline, mineral oil); AVOID oral laxatives until cleared
    fecal_impaction_with_or_without_overflow
  • lab_abnormality
    Constipation + K <3.5 OR Mg <1.5 — electrolyte-induced motility failure; replete + recheck
    hypokalemia_or_hypomagnesemia_constipation

Required inputs (28)

  • agerequired
    demographic • used at CONTEXT
    Age shifts priors: pediatric → functional with encopresis; elderly → medication-induced / opioid / fecal impaction / structural; new-onset >50 → mandatory CRC screen (Bharucha PMID 28144963)
  • sexrequired
    demographic • used at CONTEXT
    Female predominance for IBS-C / slow-transit / pelvic-floor dyssynergia; pregnancy-specific; obstetric injury sequelae (rectocele)
  • duration_and_patternrequired
    symptom • used at FRAME
    ROME IV: >6 months symptoms with last 3 months meeting criteria + <3 BM/wk + 25%+ straining/lumpy/incomplete; new-onset (especially >50) shifts toward structural / alarm features
  • bristol_stool_formrequired
    symptom • used at FRAME
    Bristol 1-2 (hard / lumpy) → constipation; mixed pattern → IBS-mixed; useful for response to therapy
  • straining_incomplete_evacuationrequired
    symptom • used at FRAME
    Straining + sensation of incomplete evacuation + digital maneuvers → pelvic-floor dyssynergia (anorectal manometry + biofeedback); part of ROME IV
  • alarm_features_red_flag_screenrequired
    symptom • used at RED_FLAGS
    Alarm: age >50 new-onset, rectal bleeding/melena, unintentional weight loss >5%, family hx CRC, anemia, nocturnal sx, sudden change in stool caliber → STAT colonoscopy + ED if obstruction concern (ACG)
  • abdominal_pain_or_bloatingrequired
    symptom • used at ENTRY
    Pain relieved by defecation + bloating → IBS-C subtype; severe pain + distension + obstipation → SBO concern (route ED)
  • overflow_or_paradoxical_diarrhea
    symptom • used at ENTRY
    Paradoxical diarrhea around impaction → fecal impaction with overflow (elderly / nursing home); manual disimpaction needed before laxatives
  • medication_review_anticholinergic_opioid_ccb_ironrequired
    history • used at CONTEXT
    Anticholinergic (TCA, antihistamine, antipsychotic), CCB (especially verapamil), opioid (chronic), iron, aluminum antacid, ondansetron, calcium-channel-blocker, antiparkinsonian → drug-induced; deprescribe or substitute
  • chronic_opioid_userequired
    history • used at CONTEXT
    Chronic opioid (chronic pain, post-surgical, cancer) → OIC distinct entity; PAMORA (methylnaltrexone / naloxegol / naldemedine) first-line per AGA PMID 30094000
  • endocrine_hypothyroid_dm_hypercalcemiarequired
    history • used at CONTEXT
    Hypothyroidism + DM2 autonomic + hypercalcemia + hyperparathyroidism → endocrine-driven; address cause first; check TSH, Ca, glucose
  • neurologic_parkinson_ms_spinal_cord
    history • used at CONTEXT
    Parkinson disease + MS + spinal cord injury + autonomic neuropathy + amyloid → neurogenic; bowel regimen + suppositories + manual evacuation; route to neuro engine for primary disease
  • colorectal_history_prior_surgery_radiation
    history • used at CONTEXT
    Prior colorectal surgery / pelvic radiation / hemorrhoids / fissure / stricture / rectocele → structural / functional outlet; consider colorectal referral
  • family_history_crc_ibd
    history • used at CONTEXT
    Family hx CRC (especially first-degree <60 or multiple) → earlier screening + workup new-onset constipation; family hx IBD → consider underlying IBD
  • pregnancy_status
    history • used at CONTEXT
    Pregnancy → physiologic + iron-induced; psyllium / PEG safe; AVOID castor oil + chronic stimulant; senna acceptable short-term
  • sbprequired
    vital • used at CONTEXT
    Hypotension + obstipation + distension → SBO with shock concern (route ED)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia + abdominal sx → SBO / sepsis overlap; bradycardia → hypothyroid
  • temp
    vital • used at CONTEXT
    Fever + constipation + distension → SBO with strangulation / perforation / diverticulitis; route ED
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Anemia (iron-deficiency) + new-onset constipation → mandatory CRC workup; leukocytosis → infectious / SBO complication
  • bmp_calcium_phosphorusrequired
    lab • used at INITIAL_WORKUP
    Hypokalemia + hypomagnesemia + hypercalcemia → motility failure; BUN/Cr for CKD with constipation (sevelamer, calcium-binders); glucose for DM2 autonomic
  • tsh_t4_freerequired
    lab • used at INITIAL_WORKUP
    TSH elevated + T4 low → hypothyroidism (severe → myxedema route); levothyroxine repletion typically resolves constipation
  • lft_albumin
    lab • used at INITIAL_WORKUP
    Albumin / LFT — nutrition / weight-loss screen; hypoalbuminemia → severe IBD / malabsorption / malignancy
  • crp_inflammation
    lab • used at INITIAL_WORKUP
    CRP — inflammatory screen if IBD / diverticulitis / malignancy concern
  • abdominal_xray_kub
    imaging • used at INITIAL_WORKUP
    KUB — stool burden visualization, megacolon, SBO, free air; useful for impaction assessment + treatment-response monitoring
  • colonoscopy_alarm_features_or_age_screen
    imaging • used at BRANCHING_WORKUP
    Colonoscopy — mandatory for new-onset >50, alarm features (bleeding, anemia, weight loss, family hx, nocturnal, caliber change); also catches CRC at screening age
  • anorectal_manometry_with_balloon_expulsion
    imaging • used at BRANCHING_WORKUP
    Anorectal manometry + balloon expulsion test → pelvic-floor dyssynergia (paradoxical contraction + failed expulsion); refers to GI motility specialist + biofeedback
  • colonic_transit_marker_or_scintigraphy
    imaging • used at BRANCHING_WORKUP
    Sitz marker (Sitzmarks) or radionuclide scintigraphy → slow-transit constipation (colonic inertia); guides prosecretory / 5HT4 / surgical consideration
  • defecography_mri_or_fluoroscopic
    imaging • used at BRANCHING_WORKUP
    Defecography (MR or fluoroscopic) → rectocele, intussusception, enterocele, pelvic-floor descent; functional outlet abnormalities

12-phase flow (12)

  1. 1FRAME
    ROME IV duration + pattern (chronic >6 mo); Bristol stool form 1-2; straining + incomplete evacuation + digital maneuvers — anchors phenotype (Bharucha AGA 2013 PMID 28144963; Vazquez ACG 2021 PMID 31000341)
    inputs: duration_and_pattern, bristol_stool_form, straining_incomplete_evacuation
    advance: ROME IV criteria evaluated + phenotype tentative
  2. 2ENTRY
    Abdominal pain / bloating (IBS-C overlap); overflow diarrhea (impaction); alarm features (RED_FLAGS); functional outlet symptoms
    inputs: abdominal_pain_or_bloating, overflow_or_paradoxical_diarrhea, alarm_features_red_flag_screen
    advance: phenotype-defining features captured
  3. 3CONTEXT
    Age + sex + vitals + medication review (anticholinergic / opioid / CCB / iron / antacid Al) + chronic opioid + endocrine (hypothyroid, DM2 autonomic, hypercalcemia, hyperparathyroidism) + neurologic (Parkinson, MS, spinal cord) + colorectal surgical / radiation / hemorrhoid / fissure / stricture / rectocele + family hx CRC/IBD + pregnancy
    inputs: age, sex, sbp, hr, medication_review_anticholinergic_opioid_ccb_iron, chronic_opioid_use, endocrine_hypothyroid_dm_hypercalcemia, neurologic_parkinson_ms_spinal_cord, colorectal_history_prior_surgery_radiation, family_history_crc_ibd, pregnancy_status
    advance: context complete
  4. 4RED_FLAGS
    Age >50 new-onset; rectal bleeding / melena; unintentional weight loss >5%; family hx CRC; iron-deficiency anemia; nocturnal sx; sudden change in stool caliber; severe pain + obstipation + distension + fever → SBO / strangulation / perforation / volvulus / diverticulitis with abscess — route ED + colonoscopy STAT
    inputs: alarm_features_red_flag_screen, sbp, temp
    advance: no immediate alarm OR routed to ED / colonoscopy
  5. 5INITIAL_WORKUP
    CBC (anemia → CRC workup); BMP + Ca + Mg + PO4 (electrolyte motility, hypercalcemia, CKD); TSH (hypothyroid); LFT + albumin (malabsorption); CRP (inflammatory); KUB (stool burden, megacolon, SBO)
    inputs: cbc_with_diff, bmp_calcium_phosphorus, tsh_t4_free, lft_albumin, crp_inflammation, abdominal_xray_kub
    actions: panel.cbc, panel.renal, panel.lft, panel.thyroid
    advance: initial workup reviewed + cause stratification
  6. 6BRANCHING_WORKUP
    Alarm features OR new-onset >50 → colonoscopy (CRC, stricture, IBD). Refractory + outlet sx → anorectal manometry + balloon expulsion (pelvic-floor dyssynergia → biofeedback). Refractory + delayed transit → Sitz marker / scintigraphy (slow-transit). Functional outlet imaging → defecography. Pregnancy → psyllium / PEG safe. Hypothyroid → TSH + T4 + levothyroxine. Hypercalcemia → PTH + workup. OIC → PAMORA per AGA. Drug-induced → deprescribe. Impaction → manual disimpaction first.
    inputs: colonoscopy_alarm_features_or_age_screen, anorectal_manometry_with_balloon_expulsion, colonic_transit_marker_or_scintigraphy, defecography_mri_or_fluoroscopic
    advance: definitive pathway selected
  7. 7DIFFERENTIAL
    Primary normal-transit IBS-C (most common); slow-transit (colonic inertia); pelvic-floor dyssynergia (outlet); opioid-induced (OIC); medication-induced (anticholinergic / CCB / iron); endocrine (hypothyroid, DM2 autonomic, hypercalcemia, hyperparathyroidism); neurologic (Parkinson, MS, spinal cord); structural (CRC, stricture, volvulus, rectocele); IBD with proctitis; pregnancy physiologic; pediatric functional with encopresis; fecal impaction with/without overflow; hospital / immobile / postoperative; electrolyte (K, Mg).
    advance: phenotype ranked
  8. 8RISK_STRATIFICATION
    Alarm-feature score (any one triggers colonoscopy); CRC risk by age/family hx; pelvic-floor severity (need biofeedback); opioid dose / chronicity (need PAMORA); impaction severity (manual vs enema vs OR); SBO severity if structural
    advance: risk stratification documented
  9. 9TREATMENT
    Lifestyle: fiber 25-30 g/d (psyllium / wheat dextrin / methylcellulose), hydration 2 L/d, exercise. Osmotic: PEG 17 g/d (first-line per AGA / ACG), lactulose 15-30 mL BID, MgOH 30 mL or Mg citrate (caution CKD). Stimulant: bisacodyl 5-10 mg PO/PR, senna 8.6-17.2 mg PO. Prosecretory: linaclotide 145 µg (IBS-C 290 µg), plecanatide 3 mg, lubiprostone 24 µg (caution pregnancy). 5HT4: prucalopride 2 mg PO daily (CIC + slow-transit). OIC PAMORA: methylnaltrexone 12 mg SC q48h, naloxegol 12.5-25 mg PO daily, naldemedine 0.2 mg PO daily. Biofeedback (pelvic-floor dyssynergia first-line). Manual disimpaction + enemas (impaction). Address cause: levothyroxine (hypothyroid), DM glycemic control + prokinetic, hypercalcemia tx, deprescribe offending meds, IBD tx routing.
    inputs: medication_review_anticholinergic_opioid_ccb_iron
    advance: stepwise ladder initiated + cause addressed
  10. 10DISPOSITION
    Home: most outpatients; lifestyle + osmotic + lifestyle counseling + return precautions; pregnancy counseling. Outpatient GI referral: refractory + alarm + pelvic-floor / slow-transit workup. ED: severe pain + obstipation + distension + fever (SBO / perforation / strangulation / diverticulitis); fecal impaction failing outpatient disimpaction. Inpatient: severe impaction + ileus + AMS + electrolyte derangement + comorbid acute illness. ICU: rare — severe ileus + volvulus + perforation + shock.
    advance: disposition assigned
  11. 11MONITORING
    BM frequency + Bristol stool form trend (1-2 → 3-5 goal); response to osmotic vs prosecretory vs PAMORA at 2-4 weeks; repeat BMP if osmotic + CKD (Mg); colonoscopy result + downstream routing; biofeedback completion in pelvic-floor; PAMORA tolerance + opioid dose tracking
    advance: response documented or escalation triggered
  12. 12FOLLOWUP
    Lifestyle counseling reinforcement (fiber + hydration + exercise + toilet posture); deprescribing offending meds; chronic IBD on biologic / mesalamine; biofeedback for pelvic-floor; surgical referral for refractory rectocele / megacolon (Hartmann or subtotal colectomy); CRC screening intervals; OIC on chronic opioid PAMORA; pregnancy obstetric coordination; pediatric NASPGHAN/ESPGHAN bowel program
    advance: long-term plan in place + follow-up scheduled