Patient handout

Chronic constipation (outpatient symptom triage)

PRODUCTION

1. Your condition

This handout is for chronic constipation (outpatient symptom triage). Your care team identified this based on: 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).

Other reasons your team may use this plan: 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); constipation + impaired evacuation + paradoxical pelvic-floor contraction on balloon expulsion / anorectal manometry — pelvic-floor dyssynergia; biofeedback first-line (not laxatives); 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).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
soluble fiber (psyllium) titrated up with adequate fluid; increase physical activity; scheduled toileting	—	—	—	First-line for chronic idiopathic constipation; psyllium has the best evidence among fibers (AGA 2013)

Plan: Chronic idiopathic constipation: lifestyle/fiber -> osmotic -> stimulant -> prosecretory/prokinetic; PAMORA for OIC; biofeedback for dyssynergia (AGA-ACG 2023; AGA 2013)

3. When to call your provider

Contact your care team if any of the following happen:

Severe pain + obstipation + distension + fever → ED workup SBO / strangulation / perforation / volvulus / diverticulitis with abscess
New rectal bleeding / hematochezia / melena → STAT colonoscopy + ED if hemodynamic instability
Iron-deficiency anemia + new-onset constipation >50 → colonoscopy + tumor workup
Refractory fecal impaction failing outpatient manual + enema → ED for sedation + manual disimpaction OR OR if obstructed
Severe hypothyroidism with myxedema features (AMS, hypothermia, hyponatremia, bradycardia) → route endo.myxedema-coma.core.v1
Severe hypercalcemia (Ca >14 + sx) → ED for IVF + bisphosphonate + calcitonin + cinacalcet
IBD flare with proctitis features → route gi.crohns.core.v1 / gi.ulcerative-colitis.core.v1
Suspected colorectal cancer (mass, weight loss, anemia, family hx) → STAT colonoscopy + oncology
OIC failing PAMORA → palliative care / pain mgmt opioid rotation + bowel regimen escalation
Pediatric refractory functional constipation → pediatric GI specialist

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

New-onset chronic constipation + age >50 + any alarm feature (rectal bleeding, melena, unintentional weight loss >5%, family hx CRC, iron-deficiency anemia, nocturnal symptoms, sudden change in stool caliber) — mandatory colonoscopy + CRC workup (Bharucha AGA 2013 PMID 28144963)
DRE confirms hard stool in rectum + paradoxical overflow diarrhea + elderly / immobile / nursing home — fecal impaction; manual disimpaction + enemas; AVOID oral laxatives until cleared
Severe pain + obstipation + distension + fever + tachycardia + hypotension OR free air on KUB — SBO / perforation / strangulation / volvulus → STAT ED + surgery consult(life-threatening)
Chronic constipation + cold intolerance + bradycardia + hyponatremia + AMS + hypothermia + non-pitting edema — severe hypothyroidism / myxedema coma; route endo.myxedema-coma.core.v1(life-threatening)
Constipation + bones/stones/groans/moans + Ca >14 + sx — severe hypercalcemia; ED for IVF + bisphosphonate + calcitonin ± cinacalcet; workup PTH + malignancy

5. Follow-up

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

6. Sources

Guideline: 2013 AGA Bharucha chronic constipation + 2021 ACG Vazquez chronic constipation + AGA 2018 OIC + NASPGHAN/ESPGHAN pediatric + ROME IV functional GI disorders