Acute Constipation in a 31-Year-Old Female with a History of Hemorrhoids

Case at a Glance

A 31-year-old female with a known history of chronic constipation and hemorrhoids presented with a two-day inability to pass stool, despite self-managing with diet, fluids, and an osmotic laxative. She reported a sensation of rectal blockage and fear of straining.

Patient's Story

The patient is a 31-year-old Māori/Pacific Islander female (height: 165 cm, weight: 86 kg, BMI: 31.6 kg/m²) who presented with a chief complaint of constipation for the past 48 hours. Her relevant medical history includes recurrent constipation, lactose intolerance, and both internal and external hemorrhoids. For the past two days, she had been proactively trying to manage her symptoms by consuming a diet rich in fruits and vegetables, ensuring adequate fluid intake, and taking a single daily dose of her prescribed osmotic laxative (macrogol, brand name Movicol). Despite these measures, she reported a persistent urge to defecate but felt a 'blockage' preventing stool passage. She was fearful of straining due to the pain and potential exacerbation of her hemorrhoids. She confirmed she was able to pass flatus and urinate without difficulty.

Initial Assessment

Based on the patient's report, the primary concern was acute constipation, with a high likelihood of fecal impaction in the rectal vault. Her ability to pass flatus made a complete bowel obstruction less likely. Her history of hemorrhoids was a significant complicating factor, as the pain would inhibit the effective straining required to pass a hard stool, creating a difficult cycle. Her current self-treatment regimen was noted to be insufficient for resolving the acute episode.

The Diagnostic Journey

The diagnosis was made clinically based on the patient's distinct and characteristic symptoms. The two-day duration without a bowel movement, combined with the sensation of rectal fullness and blockage, in the context of her chronic constipation, was sufficient to diagnose an acute episode. Further investigation, such as a digital rectal exam, was not performed at this stage but would be the next step if symptoms did not resolve. The diagnostic focus was on differentiating from a more serious obstruction and formulating a safe and effective disimpaction plan.

Final Diagnosis

Acute Constipation with suspected Fecal Impaction, secondary to Chronic Constipation, complicated by painful Hemorrhoids.

Treatment Plan

The initial community-based advice provided was to escalate the current treatment. The patient was advised to increase the dosage of her osmotic laxative (Movicol) from once daily to two or three times daily. She was instructed to continue with high fluid intake, as this is critical to the efficacy of the laxative. The goal of this intensified regimen was to soften the impacted stool to a consistency that could be passed with minimal straining, thereby avoiding trauma to her hemorrhoids.

Outcome and Follow-up

The patient initially expressed hesitation about increasing the laxative dose, concerned about the potential for inducing explosive diarrhea. However, understanding the rationale, she agreed to adhere to the escalated treatment plan. The short-term goal was the successful passage of stool and relief of her symptoms within 24-48 hours. Long-term follow-up should include a discussion about a maintenance laxative regimen, dietary modification, and lifestyle factors to prevent future episodes of impaction and manage her chronic constipation more effectively.