Case 2 Complaints of Constipation During an Office Visit
Authors:
Claudene George, MD, Assistant Professor of Medicine, Geriatrics Fellowship Program Director, Student Clerkship Director, Albert Einstein College of Medicine, Montefiore Medical Center
Laurie G. Jacobs, MD, Professor of Clinical Medicine and Vice Chair of Clinical and Educational Programs, Department of Medicine, Director, Jack and Pearl Resnick Gerontology Center, Albert Einstein College of Medicine, Montefiore Medical Center.
Setting: Outpatient office visit, patient accompanied by her daughter-in-law
Chief complaint: An 85 year old white woman comes to the office with a complaint of “constipation for several months.”
History of Present Illness:
The patient has complained of hard stools every third day, dark brown, for several months. She hasn’t noticed any change in caliber, but claims she is straining to defecate and sometimes has streaks of blood around the stool. She hasn’t changed her diet and has not been ill recently.
Question 1:
Which description can be formally considered “constipation“?
a. bowel movements every other day
b. bowel movements every third day
c. patient discomfort with defecation
d. bowel movements once a week
e. incomplete evacuation
f. all of the above
Answer: f
Medically, constipation is often defined as a frequency of <3 bowel movements a week. Patients, however, often define it as stools that are firm, too hard to expel, too small, painful or associated with a sensation of incomplete evacuation. It is generally considered a change from baseline function.
Question 2:
Could normal aging explain this patient’s constipation?
a yes
b no
Answer: b
There is no clear evidence that colonic motility declines with age in humans, but there is an increase in self-reporting of constipation and use of laxatives with aging. This could be partly due to decreases in fecal water content with aging.
Question 3:
What other elements of the history are important to the chief complaint? (check all that apply)
a. dietary content
b. fluid intake
c. activity
d. denture use
e. OTC medications and/or herbal use
f. Other medical conditions
Answer: all
Fiber intake is important in maintaining motility, but fluid intake is essential. A marked decrease in physical activity can contribute to constipation. Despite being edentulous, most individuals can chew most foods with or without dentures, however, a poorly fitting denture can produce pain and limit intake. Over-the-counter medications and herbals can influence appetite and have other adverse effects.
Past Medical History:
Hypertension – 10 years
Diabetes – 10 years
Bilateral cataract surgery – 2 and 3 years ago
Appendectomy – age 18
Medications: She has no known allergies.
atenolol 50 mg daily
diltiazem CD 300 mg daily
nortriptyline 10 mg daily
donepezil 5 mg daily
glucotrol 5 mg daily
colace, calcium, multivitamins
Question 4:
Which medications could be contributing to her constipation? Check all that apply.
a. atenolol
b. diltiazem
c. nortriptyline
d. donepezil
e. calcium
Answers: b,c,e
Some common medications which can cause constipation include:
Anticholinergics (oxybutinin)
Aluminum antacids, bismuth (Pepto bismol); calcium antacids and supplements
Anticonvulsants – phenytoin, carbamazepine, phenobarbital
Antidepressants – tricyclics
Antihistamines
Antilipemics – cholestyramine, colestipol
Antiparkinsonian drugs: bromocriptine, Sinemet, amantadine
Antipsychotics – haloperidol, risperidone
Antispasmotics – oxybutynin, opiate or barbiturates
Diuretics, Calcium channel blockers
Iron supplements
Laxative misuse and fiber without sufficient fluids
NSAIDS (nonsteroidal anti-inflammatory agents), Opiates, Phenothiazines
Review of Systems:
The patient notes significant fatigue with her usual activities. She eats and sleeps well. Her daughter-in-law describes her as being “depressed” in that she does not do many of the activities she used to enjoy, and as having memory problems. The patient says she has “some mild memory problems.” This has been going on for several years, and she has been treated with an antidepressant, nortriptyline, for two years, without any apparent change. Her doctor just started her on donepezil.
Question 5:
Which diagnoses (apart from the adverse effects of the medications listed to treat them) could be contributing to her “constipation”?
a. diabetes mellitus
b. depression
c. dementia
d. hypertension
e. a, b, and c
f. all of the above
Answer: e
Constipation or diarrhea may occur with autonomic neuropathy, most commonly caused by diabetes. Changes in bowel habits and constipation can accompany changes in diet that may accompany depression, in addition to adverse effects of antidepressant medications, particularly the anticholanergic tricyclics. Cognition is important as patients with dementia may miss meals without awareness, or eat more often, and may also have a change in diet. Emotional status, including anxiety and depression, both affect appetite.
Question 6:
Should alcoholism be considered in trying to explain this patient’s constipation, cognition, and affect?
a. Yes
b. No
Answer: a
Yes, alcohol abuse can continue or begin in late life and should be considered here. The older person is more likely to reach a higher blood alcohol level given the same amount, and present with greater intoxication. Sustained use can produce cognitive decline, and be associated with anxiety with withdrawal, and in some individuals, be associated with depression. Constipation could be due to inadequate food and fluid intake compounded by the diuretic effect of the alcohol.
Question 7:
Which other endocrinologic conditions could explain this patient’s constipation, cognition and affect?
a. hypothyroidism
b. hyperthyroidism
c. hyperparathyroidism
d. a,b,and c
e. a and c
f. none of the above
Answer: a,c
Hypothyroidism identified by an elevated TSH level has been found to occur in 17.5% of adults over age 75, with 0.5% overtly hypothyroid. They can present with fatigue (68%), “mental slowness” (45%), constipation (33%), cold intolerance (35%), depression (28%), dry skin (35%) and other signs and symptoms common in older adults in general which makes consideration and laboratory testing critical. Hyperthyroidism is often associated with diarrhea, rather than constipation, although this symptom is more commonly identified in younger patients (18% of elderly vs. 43% young). As many as half the cases of hyperparathyroidism are diagnosed in older adults, and can also present with subtle signs and symptoms prevalent in old age so that its identification may be a clinical challenge. Gastrointestinal signs and symptoms include peptic ulcer disease, pancreatitis, and constipation. Hypercalcemia can cause polyuria, nephrocalcinosis and nethrolithiasis. Hypertension is frequently associated but a causal mechanism is unclear. In addition, memory loss, delirium, personality changes or depression can be identified in older adults with hyperparathyroidism.
Question 8:
The MMSE score is 19, below the cutoff for normal cognitive function. She admits to having some memory problems. What does this score indicate? Check all that apply.
a. She has “mild cognitive impairment” and does qualify for having dementia or
depression
b. She has a cognitive impairment appropriate for age
c. She has dementia which is diagnosed by the low MMSE (Minimental state
examination) score
d. She may have dementia and further testing is needed
e. She has depression which is causing the low MMSE score
f. She may have depression and further evaluation is needed
Answer: d, f
The MMSE is not a diagnostic test, and the diagnosis of dementia requires demonstration of acquired cognitive decline in memory and at least one other cognitive function (eg. language, visual spatial, executive) sufficient to affect daily life in an alert person. She may have dementia and/or depression, but the score falls below that for mild cognitive impairment. Further neuropsychological evaluation is needed.
Question 9:
What further testing should be done at this time?
a. MRI of the brain
b. TSH, VDRL, B12, folate
c. Neuropsychological testing
d. HIV, Lyme titer
e. CSF examination
f. a, b, and c
g. All of the above
Answer: f
Although it remains controversial, imaging of the brain is often done to evaluate for stroke and structural disease. The likelihood of detecting structural lesions is increased with onset of symptoms before age 60, focal neurologic signs or symptoms, abrupt onset or rapid decline, predisposing conditions. A detailed clinical interview and formal neuropsychological testing can assist in separating the diagnosis of depression from dementia. A CSF examination, HIV and lyme testing is more rarely undertaken due to the low prevalence of these disorders causing subtle dementia in an 85 year old woman, and only in circumstances suggestive of chronic infection (syphilis, lyme, etc), metastatic disease or normal pressure hydrocephalus.
Review of Systems, continued:
The patient also describes having urinary incontinence four or five times a day and night for five years, as “I know that I have to go, but I never get to the bathroom in time.” She began the oxybutinin a year ago and has had some improvement. She denies fecal incontinence.
Question 10:
This history is most consistent with which type of urinary incontinence?
a. transient incontinence
b. urinary tract infection
c. urge incontinence
d. stress incontinence
e. overflow incontinence
f. none of the above
Answer: c
Urinary incontinence can be present in about 30% of community-dwelling older women. Although transient incontinence implies that it is not persistent, the underlying causes, most of which are not due to genitourinary pathology, may reoccur. Examples include polyuria from uncontrolled diabetes, recurrent urinary tract infections, etc. Established incontinence includes urge incontinence or detrussor overactivity characterized by involuntary bladder contractions either due to CNS disease or intrinsic to the bladder. The history is that of an urgency to void rapidly followed by involuntary voiding. Leakage is moderate to large, with a post-void residual of less than 50cc. Stress incontinence is the second most common type and is usually the result of pelvic muscle laxity and “urethral hypermobility.” The defect is in urethral support rather than sphincter incompetence, and incontinence occurs with episodes of increased abdominal pressure such as seen with coughing. Outlet obstruction is much more common in older men. Leakage is more chronic and in small amounts.
Question 11:
What should be done in addition to a history – a detailed description of episodes – and a physical examination including a pelvic and neurologic exam, as part of the initial evaluation of her urinary incontinence?
a. post-void residual
b. urinalysis
c. chemistries (electrolytes, BUN, glucose, creatinine)
d. urodynamic testing
e. a, b, c
f. all of the above
Answer: e
An important first step is to identify those with overflow incontinence indicated by a high post-void residual. These patients may have bladder outlet obstruction or an underactive detrussor, and require further diagnostic testing by urodynamic studies to be differentiated. The history and physical examination should provide a working diagnosis. Urinalysis and chemistries assist in evaluating transient causes, contributing factors and renal insufficiency from hydronephrosis. Urodynamic studies is useful in a subset, but not all patients with established urinary incontinence.
Social History:
The patient lives alone in an apartment. She is a widow and has two sons, one of whom lives nearby. She has a high school education and was employed as a secretary years ago. She denies smoking or drinking, now or in the past.
Physical Examination:
The patient is a thin, alert elderly woman appearing her stated age, in no distress. She walked independently and was cooperative. BP 178/80 HR 60 RR 18, weight 126 lbs, height 5 ft. 4 in. HEENT- edentulous, unremarkable; Thyroid - not palpable; Chest - clear, breasts small without mass, heart - RRR w/o murmur; abdomen - soft, no mass, normal tone, dark brown stool, guaiac negative; Ext. 1+ dependent edema. Neurological examination alert, oriented x2, MMSE 21/30, cranial nerves intact, normal tone, reflexes depressed (1+) throughout, no tremor, strength 4- throughout, sensory slightly decreased to sharp and dull in lower legs, gait within normal limits.
Laboratory Data:
White Blood Cell count 6.0 with 78% polys, 14% lymphs, 3% monos, 5%eo
Hemoglobin/Hematocrit 10.1 (12.3 – 15.5 g/dl)/ 32 (36.0-45.0 %)
Mean Corpuscular Volume 96 (80-96 fl) Reticulocyte count 2.2%
Chemistries: Na 140 Cl 104 K 4.6 CO2 26 BUN 48 Cr 2.2 Glucose 186
Question 12:
The anemia could be due to: (check all that apply)
a. Normal aging
b. iron deficiency
c. anemia of chronic disease
d. B12 or folate deficiency
e. Myelodysplastic syndrome
f. hypothyroidism
g. all of the above
Answer: b, c, d, e, f
Although anemia is more prevalent (5-51% depending on patient samples) as aging proceeds, it cannot be assumed to be due to aging alone. The MCV is within the normal range, categorizing this as a normocytic anemia, but it is at the upper limit of normal, so that a macrocytic anemia could be invoked as well, or a mixed picture. The reticulocyte count is often useful initially to direct further testing. Thus early iron deficiency or anemia of chronic disease can be considered. Macrocytic causes would include B12 and folate deficiency, myelodysplastic syndromes, hypothyroidism, liver disease.
Laboratory Data, continued: In view of the constipation, it was critical to ensure that the anemia was not due to iron deficiency caused by a colonic lesion. Laboratory testing was done as the patient did not want to undergo a bone marrow aspiration unless absolutely necessary.
Iron 52 (65-175) Transferrin 235 (204-360) TIBC 294 (250-410)
% saturation 18 (26-42) Ferritin 89 (10-150)
Question 13:
Can iron deficiency be sufficiently eliminated based upon the laboratory testing?
a. yes with 90% probability or so, so that the decision to do a bone marrow aspiration can be forestalled for now
b. no, a bone marrow biopsy is indicated
Answer: a
Iron stores are often assessed by measurement of the serum iron, total iron-binding capacity (TIBC), transferrin saturation, and ferritin. An elevated TIBC is most often found in iron deficiency, and low values may be found with anemia of chronic disease and malnutrition. The transferrin saturation (serum iron x 100/TIBC) has a mean about 7% in iron deficiency, compared with a mean of about 15% in anemia of chronic disease, and is between 20 – 45% in normal individuals. In studies of the elderly, the serum ferritin have been found to be useful, with values less than 18mg/L are associated with a greater than 95% probability of iron deficiency, and values greater than 100mg/L associated with a probability of less than 10% of iron deficiency. It appears that this patient has a low likelihood of iron deficiency. One may choose to do a bone marrow to be more certain if this was the decision point regarding whether she should have a colonoscopy to rule out a colonic malignancy. This is a circumstance in which clinical decision-making, patient preference, and the sense of the need to be certain must be weighed carefully by the physician, with the patient and her family. If the colonoscopy were to be done anyway, then this data makes the likelihood of iron deficiency low.