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symptom.constipation.v1

Chronic constipation (outpatient symptom triage)

symptomchronicundifferentiatedadultgeriatric
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Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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ROME IV criteria evaluated + phenotype tentative

Patient inputs (28)

Age shifts priors: pediatric → functional with encopresis; elderly → medication-induced / opioid / fecal impaction / structural; new-onset >50 → mandatory CRC screen (Bharucha PMID 28144963)

Female predominance for IBS-C / slow-transit / pelvic-floor dyssynergia; pregnancy-specific; obstetric injury sequelae (rectocele)

Anticholinergic (TCA, antihistamine, antipsychotic), CCB (especially verapamil), opioid (chronic), iron, aluminum antacid, ondansetron, calcium-channel-blocker, antiparkinsonian → drug-induced; deprescribe or substitute

Chronic opioid (chronic pain, post-surgical, cancer) → OIC distinct entity; PAMORA (methylnaltrexone / naloxegol / naldemedine) first-line per AGA PMID 30094000

Hypothyroidism + DM2 autonomic + hypercalcemia + hyperparathyroidism → endocrine-driven; address cause first; check TSH, Ca, glucose

Hypotension + obstipation + distension → SBO with shock concern (route ED)

Tachycardia + abdominal sx → SBO / sepsis overlap; bradycardia → hypothyroid

Pain relieved by defecation + bloating → IBS-C subtype; severe pain + distension + obstipation → SBO concern (route ED)

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 1-2 (hard / lumpy) → constipation; mixed pattern → IBS-mixed; useful for response to therapy

Straining + sensation of incomplete evacuation + digital maneuvers → pelvic-floor dyssynergia (anorectal manometry + biofeedback); part of ROME IV

Anemia (iron-deficiency) + new-onset constipation → mandatory CRC workup; leukocytosis → infectious / SBO complication

Hypokalemia + hypomagnesemia + hypercalcemia → motility failure; BUN/Cr for CKD with constipation (sevelamer, calcium-binders); glucose for DM2 autonomic

TSH elevated + T4 low → hypothyroidism (severe → myxedema route); levothyroxine repletion typically resolves constipation

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)

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 + balloon expulsion test → pelvic-floor dyssynergia (paradoxical contraction + failed expulsion); refers to GI motility specialist + biofeedback

Sitz marker (Sitzmarks) or radionuclide scintigraphy → slow-transit constipation (colonic inertia); guides prosecretory / 5HT4 / surgical consideration

Defecography (MR or fluoroscopic) → rectocele, intussusception, enterocele, pelvic-floor descent; functional outlet abnormalities

Parkinson disease + MS + spinal cord injury + autonomic neuropathy + amyloid → neurogenic; bowel regimen + suppositories + manual evacuation; route to neuro engine for primary disease

Prior colorectal surgery / pelvic radiation / hemorrhoids / fissure / stricture / rectocele → structural / functional outlet; consider colorectal referral

Family hx CRC (especially first-degree <60 or multiple) → earlier screening + workup new-onset constipation; family hx IBD → consider underlying IBD

Pregnancy → physiologic + iron-induced; psyllium / PEG safe; AVOID castor oil + chronic stimulant; senna acceptable short-term

Fever + constipation + distension → SBO with strangulation / perforation / diverticulitis; route ED

Paradoxical diarrhea around impaction → fecal impaction with overflow (elderly / nursing home); manual disimpaction needed before laxatives

Albumin / LFT — nutrition / weight-loss screen; hypoalbuminemia → severe IBD / malabsorption / malignancy

CRP — inflammatory screen if IBD / diverticulitis / malignancy concern

KUB — stool burden visualization, megacolon, SBO, free air; useful for impaction assessment + treatment-response monitoring

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningsbo_perforation_strangulation_suspicion
    Severe pain + obstipation + distension + fever + tachycardia + hypotension OR free air on KUB — SBO / perforation / strangulation / volvulus → STAT ED + surgery consult
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_hypothyroidism_myxedema_features
    Chronic constipation + cold intolerance + bradycardia + hyponatremia + AMS + hypothermia + non-pitting edema — severe hypothyroidism / myxedema coma; route endo.myxedema-coma.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverealarm_features_new_onset_age_over_50
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefecal_impaction_with_overflow
    DRE confirms hard stool in rectum + paradoxical overflow diarrhea + elderly / immobile / nursing home — fecal impaction; manual disimpaction + enemas; AVOID oral laxatives until cleared
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypercalcemia_severe_with_constipation
    Constipation + bones/stones/groans/moans + Ca >14 + sx — severe hypercalcemia; ED for IVF + bisphosphonate + calcitonin ± cinacalcet; workup PTH + malignancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateopioid_induced_constipation_refractory
    Chronic opioid + constipation refractory to osmotic + stimulant — OIC; PAMORA (methylnaltrexone 12 mg SC q48h OR naloxegol 25 mg PO daily OR naldemedine 0.2 mg PO daily) per AGA PMID 30094000
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepelvic_floor_dyssynergia_outlet
    Refractory constipation + outlet symptoms (straining, incomplete evacuation, digital maneuvers) + paradoxical pelvic-floor contraction on DRE + balloon expulsion fails + anorectal manometry abnormal — pelvic-floor dyssynergia; BIOFEEDBACK first-line (not laxatives) per AGA PMID 28144963
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Chronic idiopathic constipation: lifestyle/fiber -> osmotic -> stimulant -> prosecretory/prokinetic; PAMORA for OIC; biofeedback for dyssynergia (AGA-ACG 2023; AGA 2013)
axis: chronic_constipation_ladderstep 1 - Lifestyle + soluble fiber (first-line)
Selected step "Lifestyle + soluble fiber (first-line)" — Functional / normal-transit constipation without alarm features
  • soluble fiber (psyllium) titrated up with adequate fluid; increase physical activity; scheduled toileting
    first line
    bulking agent / lifestyle
    triggers: normal_transit, no_alarm_features
    First-line for chronic idiopathic constipation; psyllium has the best evidence among fibers (AGA 2013)

outpatient playbook — drug actions (12)

  1. 1. lifestyle (fiber + hydration + exercise + toilet posture)
    Fiber 25-30 g/d (psyllium 5-10 g PO daily, wheat dextrin, methylcellulose); hydration 2 L/d; daily exercise; toilet posture (squatty potty); routine BM time post-meal (gastrocolic reflex) • PO + behavioral • daily
    trigger: All chronic constipation — first step
    AGA / ACG — first-line; psyllium has most evidence; methylcellulose / wheat dextrin alternatives if bloating; gradual titration to minimize bloating
  2. 2. polyethylene glycol (PEG) 3350
    17 g PO daily (1 capful or packet in 8 oz water); titrate to soft stool • PO • daily
    trigger: Inadequate response to lifestyle after 2-4 weeks
    AGA / ACG first-line osmotic — best evidence vs other osmotic; minimal electrolyte risk; safe in pregnancy + elderly + CKD; titratable
  3. 3. lactulose OR magnesium-based osmotic
    Lactulose 15-30 mL PO BID OR Milk of Magnesia 30 mL PO daily (caution CKD); Mg citrate 195-300 mL (acute clean-out only) • PO • BID-daily
    trigger: PEG-intolerant or insufficient
    Lactulose causes bloating + flatus; Mg-based — AVOID in CKD (hypermagnesemia risk); Mg citrate for acute clean-out before colonoscopy
  4. 4. stimulant (bisacodyl OR senna)
    Bisacodyl 5-10 mg PO at bedtime OR 10 mg PR PRN; Senna 8.6-17.2 mg PO at bedtime (start low, titrate); maximum 4 tabs daily • PO/PR • daily-PRN
    trigger: Insufficient osmotic response OR rescue
    Effective short-term; chronic use historically discouraged but recent data shows safety; useful for OIC adjunct, slow-transit, hospital constipation
  5. 5. linaclotide (prosecretory)
    145 µg PO daily 30 min before breakfast (CIC); 290 µg PO daily (IBS-C) • PO • daily
    trigger: Chronic idiopathic constipation OR IBS-C refractory to step 1-4 (Vazquez ACG 2021 PMID 31000341)
    Guanylate cyclase-C agonist; ACG guideline-supported; diarrhea most common AE; AVOID in pediatric <6 yr (FDA boxed warning)
  6. 6. plecanatide (prosecretory)
    3 mg PO daily • PO • daily
    trigger: CIC OR IBS-C alternative to linaclotide
    Newer guanylate cyclase-C agonist; pH-dependent activation may reduce diarrhea AE vs linaclotide
  7. 7. lubiprostone (chloride channel activator)
    24 µg PO BID (CIC); 8 µg PO BID (IBS-C in women); 24 µg PO BID (OIC, chronic non-cancer pain) • PO • BID
    trigger: CIC, IBS-C in women, OIC alternative
    Chloride channel-2 activator; nausea most common AE (take with food); AVOID in pregnancy (FDA category C, reduced category C; insufficient data)
  8. 8. prucalopride (5HT4 agonist)
    2 mg PO daily (1 mg in CKD eGFR <30 or elderly) • PO • daily
    trigger: CIC + slow-transit refractory to step 1-7
    Highly selective 5HT4 agonist; lower cardiac risk vs older 5HT4 (cisapride, tegaserod withdrawn); EU + US approved
  9. 9. methylnaltrexone (PAMORA — OIC SC)
    12 mg SC q48h (38-114 kg); weight-based 0.15 mg/kg if <38 kg or >114 kg • SC • q48h PRN
    trigger: Opioid-induced constipation (OIC) refractory to laxatives per AGA PMID 30094000
    Peripheral mu-opioid antagonist; does not cross BBB → preserves central analgesia; CI with bowel obstruction risk
  10. 10. naloxegol (PAMORA — OIC PO)
    25 mg PO daily; 12.5 mg if CKD eGFR <60 or on moderate CYP3A4 inhibitor • PO • daily
    trigger: OIC chronic non-cancer pain PO option
    PEGylated naloxone; AVOID with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin); take 1 hr before / 2 hr after first meal
  11. 11. naldemedine (PAMORA — OIC PO)
    0.2 mg PO daily • PO • daily
    trigger: OIC PO alternative (cancer + non-cancer pain)
    Once-daily; well-tolerated; minor drug-drug interactions vs naloxegol
  12. 12. manual disimpaction + enemas (fecal impaction)
    Manual evacuation under analgesia; saline enema 250 mL OR mineral oil enema OR phosphate enema (caution CKD/elderly hyperphosphatemia) • PR + manual • PRN
    trigger: Fecal impaction (DRE confirms; AVOID oral laxatives until cleared)
    Disimpaction MUST precede oral laxative restart; otherwise overflow + perforation risk; bowel regimen (PEG + senna) post-clearance

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic constipation (outpatient symptom triage)** (symptom.constipation.v1).
Phenotype framing: 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).
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Chronic idiopathic constipation: lifestyle/fiber -> osmotic -> stimulant -> prosecretory/prokinetic; PAMORA for OIC; biofeedback for dyssynergia (AGA-ACG 2023; AGA 2013)** — step "Lifestyle + soluble fiber (first-line)".
1. soluble fiber (psyllium) titrated up with adequate fluid; increase physical activity; scheduled toileting (bulking agent / lifestyle, first line) — First-line for chronic idiopathic constipation; psyllium has the best evidence among fibers (AGA 2013)

Setting playbook (outpatient) — Pattern-anchored chronic constipation triage (normal-transit IBS-C vs slow-transit vs pelvic-floor dyssynergia vs OIC vs medication-induced vs endocrine vs structural-alarm); rule out CRC and structural causes in new-onset >50 or alarm features; stepwise pharmacologic ladder per AGA / ACG (Bharucha AGA 2013 PMID 28144963; Vazquez ACG 2021 PMID 31000341); address cause (deprescribe, levothyroxine, glycemic control, biofeedback, PAMORA, manual disimpaction)
2. lifestyle (fiber + hydration + exercise + toilet posture) Fiber 25-30 g/d (psyllium 5-10 g PO daily, wheat dextrin, methylcellulose); hydration 2 L/d; daily exercise; toilet posture (squatty potty); routine BM time post-meal (gastrocolic reflex) PO + behavioral daily — All chronic constipation — first step (AGA / ACG — first-line; psyllium has most evidence; methylcellulose / wheat dextrin alternatives if bloating; gradual titration to minimize bloating)
3. polyethylene glycol (PEG) 3350 17 g PO daily (1 capful or packet in 8 oz water); titrate to soft stool PO daily — Inadequate response to lifestyle after 2-4 weeks (AGA / ACG first-line osmotic — best evidence vs other osmotic; minimal electrolyte risk; safe in pregnancy + elderly + CKD; titratable)
4. lactulose OR magnesium-based osmotic Lactulose 15-30 mL PO BID OR Milk of Magnesia 30 mL PO daily (caution CKD); Mg citrate 195-300 mL (acute clean-out only) PO BID-daily — PEG-intolerant or insufficient (Lactulose causes bloating + flatus; Mg-based — AVOID in CKD (hypermagnesemia risk); Mg citrate for acute clean-out before colonoscopy)
5. stimulant (bisacodyl OR senna) Bisacodyl 5-10 mg PO at bedtime OR 10 mg PR PRN; Senna 8.6-17.2 mg PO at bedtime (start low, titrate); maximum 4 tabs daily PO/PR daily-PRN — Insufficient osmotic response OR rescue (Effective short-term; chronic use historically discouraged but recent data shows safety; useful for OIC adjunct, slow-transit, hospital constipation)
6. linaclotide (prosecretory) 145 µg PO daily 30 min before breakfast (CIC); 290 µg PO daily (IBS-C) PO daily — Chronic idiopathic constipation OR IBS-C refractory to step 1-4 (Vazquez ACG 2021 PMID 31000341) (Guanylate cyclase-C agonist; ACG guideline-supported; diarrhea most common AE; AVOID in pediatric <6 yr (FDA boxed warning))
7. plecanatide (prosecretory) 3 mg PO daily PO daily — CIC OR IBS-C alternative to linaclotide (Newer guanylate cyclase-C agonist; pH-dependent activation may reduce diarrhea AE vs linaclotide)
8. lubiprostone (chloride channel activator) 24 µg PO BID (CIC); 8 µg PO BID (IBS-C in women); 24 µg PO BID (OIC, chronic non-cancer pain) PO BID — CIC, IBS-C in women, OIC alternative (Chloride channel-2 activator; nausea most common AE (take with food); AVOID in pregnancy (FDA category C, reduced category C; insufficient data))
9. prucalopride (5HT4 agonist) 2 mg PO daily (1 mg in CKD eGFR <30 or elderly) PO daily — CIC + slow-transit refractory to step 1-7 (Highly selective 5HT4 agonist; lower cardiac risk vs older 5HT4 (cisapride, tegaserod withdrawn); EU + US approved)
10. methylnaltrexone (PAMORA — OIC SC) 12 mg SC q48h (38-114 kg); weight-based 0.15 mg/kg if <38 kg or >114 kg SC q48h PRN — Opioid-induced constipation (OIC) refractory to laxatives per AGA PMID 30094000 (Peripheral mu-opioid antagonist; does not cross BBB → preserves central analgesia; CI with bowel obstruction risk)
11. naloxegol (PAMORA — OIC PO) 25 mg PO daily; 12.5 mg if CKD eGFR <60 or on moderate CYP3A4 inhibitor PO daily — OIC chronic non-cancer pain PO option (PEGylated naloxone; AVOID with strong CYP3A4 inhibitors (e.g., ketoconazole, clarithromycin); take 1 hr before / 2 hr after first meal)
12. naldemedine (PAMORA — OIC PO) 0.2 mg PO daily PO daily — OIC PO alternative (cancer + non-cancer pain) (Once-daily; well-tolerated; minor drug-drug interactions vs naloxegol)
13. manual disimpaction + enemas (fecal impaction) Manual evacuation under analgesia; saline enema 250 mL OR mineral oil enema OR phosphate enema (caution CKD/elderly hyperphosphatemia) PR + manual PRN — Fecal impaction (DRE confirms; AVOID oral laxatives until cleared) (Disimpaction MUST precede oral laxative restart; otherwise overflow + perforation risk; bowel regimen (PEG + senna) post-clearance)

Non-pharmacologic actions:
- Toilet-posture education (squatty potty / footstool — biomechanical advantage)
- Behavioral: scheduled defecation 15-30 min post-meal (gastrocolic reflex)
- Deprescribe offending medications when feasible (anticholinergic, CCB, iron, aluminum antacid, opioid taper if pain-controlled, ondansetron alternative)
- Biofeedback referral for pelvic-floor dyssynergia (anorectal manometry confirmed) — first-line per AGA / ACG
- Pelvic-floor physical therapy + relaxation training
- Surgical referral for: refractory rectocele, megacolon failing medical, persistent slow-transit failing all medical (subtotal colectomy with ileorectal anastomosis as last resort)
- Pediatric: NASPGHAN/ESPGHAN bowel program (PEG 1-1.5 g/kg/d disimpaction + 0.4 g/kg/d maintenance + behavioral + reward chart)
- GI referral: alarm features, refractory after step 1-4, OIC, suspected slow-transit / dyssynergia, suspected IBD or CRC, pediatric refractory
- Colorectal surgery referral: structural outlet abnormality (rectocele, intussusception, prolapse), megacolon, refractory slow-transit

AVOID / contraindication checks:
- Exclude/treat alarm features (CRC, obstruction) before chronic laxative therapy in new onset >50 or red flags
- Do NOT give oral laxatives in suspected bowel obstruction or before disimpaction of fecal impaction
- Linaclotide/plecanatide contraindicated in known/suspected mechanical GI obstruction and in pediatric patients

Monitoring

Regimen monitoring:
- bowel-movement frequency + Bristol stool form + symptom response
- reassess for dyssynergia (anorectal manometry/balloon expulsion) if refractory to laxatives
- colonoscopy if alarm features or age-appropriate screening due

Setting (outpatient) monitoring:
- BM frequency + Bristol stool form (1-2 → goal 3-5) every 2-4 weeks initially
- Response to step (osmotic vs prosecretory vs PAMORA) at 4 weeks; step up if no response
- BMP + Mg if on Mg-based osmotic + CKD
- TSH 6 weeks after levothyroxine initiation/adjustment
- Colonoscopy result + downstream routing (CRC → oncology; stricture → colorectal; IBD → gi.crohns / gi.ulcerative-colitis)
- Biofeedback session attendance + symptom improvement
- PAMORA tolerance (transient abdominal pain, diarrhea); opioid dose tracking
- Repeat CBC at 3 months if anemia found at workup
- Pediatric stool diary + encopresis episodes

Follow-up plan: 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
- Close-out criterion: long-term plan in place + follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: outpatient — Pattern-anchored chronic constipation triage (normal-transit IBS-C vs slow-transit vs pelvic-floor dyssynergia vs OIC vs medication-induced vs endocrine vs structural-alarm); rule out CRC and structural causes in new-onset >50 or alarm features; stepwise pharmacologic ladder per AGA / ACG (Bharucha AGA 2013 PMID 28144963; Vazquez ACG 2021 PMID 31000341); address cause (deprescribe, levothyroxine, glycemic control, biofeedback, PAMORA, manual disimpaction)

Disposition criteria:
- Home (most): stepwise ladder + lifestyle counseling + return precautions + scheduled outpatient follow-up
- GI outpatient referral: refractory after step 1-4, alarm features, suspected slow-transit / dyssynergia, OIC requiring PAMORA
- Colorectal surgery referral: rectocele, megacolon, refractory slow-transit, structural outlet
- ED: severe pain + obstipation + distension + fever; suspected SBO / perforation / strangulation; severe hypercalcemia; severe hypothyroidism with myxedema; failed outpatient impaction disimpaction
- Inpatient: severe impaction + ileus + AMS + electrolyte derangement; comorbid acute illness; postoperative constipation with ileus
- ICU (rare): severe ileus with perforation / sepsis / shock; volvulus with strangulation; megacolon with toxic features (rare in constipation, more in IBD)

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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
- [SEVERE] 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)

Citations

- 2013 AGA Bharucha chronic constipation + 2021 ACG Vazquez chronic constipation + AGA 2018 OIC + NASPGHAN/ESPGHAN pediatric + ROME IV functional GI disorders [PMID:37211380](https://pubmed.ncbi.nlm.nih.gov/37211380/)
- Cited evidence (PMID 27033126) [PMID:27033126](https://pubmed.ncbi.nlm.nih.gov/27033126/)

Last reconciled with current guidelines: 2026-05-31.
References
  • 2013 AGA Bharucha chronic constipation + 2021 ACG Vazquez chronic constipation + AGA 2018 OIC + NASPGHAN/ESPGHAN pediatric + ROME IV functional GI disorders — PMID:37211380
  • Cited evidence (PMID 27033126) — PMID:27033126