Pain in Primary Care

Constipation and Cramping: A Slam-Dunk Diagnosis?

Charles P. Vega, MD


August 03, 2022

In my continuing focus on issues of pain management in primary care, this month I'm presenting the clinical scenario of a woman with a 1-year history of constipation and abdominal cramping. I'll tell you what I plan to do, but I'm most interested in crowdsourcing a response from all of you to collectively determine best practice. So please answer the polling question and contribute your thoughts in the comments, whether you agree or disagree.

The Patient

Brenda is a 35-year-old woman who has experienced increasing constipation with abdominal discomfort for the past year. "I thought it was just stress and would go away, and I have been too busy to come in sooner," she tells you.

She has a hard bowel movement every other day. She feels generalized abdominal cramping throughout the day. This cramping is relieved for about 2 hours after she has a bowel movement. Foods high in fat content make the discomfort worse. She has reduced her overall food consumption and reports a weight loss of 5 lb in the past 6 months. She tried over-the-counter docusate sodium and bismuth subsalicylate for her symptoms, without improvement.

The patient denies having blood or mucus in her stool, and also denies melena. She has no fever or dysuria. Her last menstrual period was 10 days ago. She has about 4 days of menstrual flow every 30 days. She's had one male and one female sexual partner and has not been sexually active in 6 years. She says that she feels sad from time to time but denies anhedonia.

She reports no history of previous abdominal symptoms, no chronic illnesses, and no previous surgeries.

Brenda is an executive at a marketing firm. She lives alone and has a busy work schedule. She has one alcoholic drink each night and denies use of any other substances.

Her body mass index is 28, and her vital signs are normal. The only abnormality on her physical exam is diffuse abdominal tenderness to palpation without guarding.


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