Stercoral ulcer & laxatives

We discussed a case of an elderly woman with hx of CAD c/b MI, hx of recent PEA arrest due to high-grade AV block s/p PPM, HFrEF, and afib, who presented with acute diffuse abdominal pain, not passing gas, and large volume bright red blood per rectum, found to have severe constipation causing fecal impaction & rectal perforation.

LGIB ddx

  • Structural:  diverticulosis, hemorrhoids, post-polypectomy bleeding, polyps, malignancy, anal fissure, colonic / rectal ulcers
  • Vascular:  ischemic colitis, angiodysplasias, colonic / rectal varices, congenital or systemic diseases causing vascular anomalies (HHT, CREST), tumors (hemangiomas, Kaposi sarcoma)
  • Inflammatory:  IBD, infectious, radiation

Management of constipation & laxatives

  • PO hydration, exercise, fiber
  • Bulking:  psyllium, wheat dextrin, cellulose
  • Osmotic:  miralax, lactulose, magnesium citrate
  • Stimulant:  senna, bisacodyl
  • Stool softeners / enemas:  colace, tap water, soap suds, Fleet (glycerin, mineral oil, sodium phosphate)
  • Opioid antagonists:  methylnaltrexone, naloxegol

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