14.5 Constipation, Hemorrhoids, Peptic Ulcer Disease & Other Upper and Lower GI Disorders
Key Takeaways
Functional constipation is first treated with fiber and fluids, then osmotic laxatives such as polyethylene glycol; fiber, PEG, and lactulose are preferred in pregnancy, while mineral and castor oils are avoided.
Internal hemorrhoids cause painless bright red bleeding and prolapse, while a thrombosed external hemorrhoid causes acute pain and can be excised within about 72 hours; rectal bleeding at 45 or older or with red flags needs colonoscopy.
H. pylori is diagnosed with a urea breath test or stool antigen after stopping PPIs for 2 weeks, and bismuth quadruple therapy for 14 days is a preferred first-line regimen, followed by a test of cure.
People with inflammatory bowel disease should conceive during remission and continue most maintenance drugs, but methotrexate must be stopped at least 3 months before conception.
Celiac disease is screened with tissue transglutaminase IgA plus total IgA while the patient is eating gluten, and it can cause iron deficiency, osteoporosis, and infertility.
Chronic Constipation
Rome IV functional constipation: For at least 3 months (symptom onset 6 or more months earlier), at least two of the following in more than a quarter of bowel movements: straining, lumpy or hard stools, a feeling of incomplete evacuation, a sense of blockage, manual maneuvers, or fewer than 3 spontaneous movements per week, without meeting IBS criteria.
Look for Secondary Causes and Red Flags
- Secondary causes: Hypothyroidism, hypercalcemia, diabetes, pregnancy, and drugs (opioids, iron, calcium, anticholinergics, calcium channel blockers, antipsychotics).
- Red flags needing colonoscopy: New onset at 45 or older without prior screening, rectal bleeding, iron deficiency anemia, unintentional weight loss, or a family history of colorectal cancer or IBD.
Stepwise Treatment
- Fiber (psyllium, 20–30 g/day total) with adequate fluids and activity.
- Osmotic laxatives: Polyethylene glycol 3350 (first-line, well tolerated), lactulose, or magnesium hydroxide (avoid in renal failure).
- Stimulant laxatives: Senna or bisacodyl as rescue or adjuncts.
- Prescription secretagogues (linaclotide, plecanatide, lubiprostone) and the 5-HT4 agonist prucalopride for refractory constipation.
- Dyssynergic defecation (straining against a closed pelvic floor) responds to biofeedback pelvic floor therapy, not laxatives alone.
Docusate (a stool softener) has limited evidence on its own. In pregnancy, use fiber, PEG, lactulose, and short-term senna or bisacodyl; avoid mineral oil (reduces fat-soluble vitamin absorption) and castor oil (can stimulate contractions).
Hemorrhoids
| Feature | Internal | External |
|---|---|---|
| Location | Above the dentate line (visceral innervation) | Below the dentate line (somatic innervation) |
| Symptoms | Painless bright red bleeding, prolapse, mucus, itching | Itching and swelling; acute severe pain when thrombosed |
| Grading | Grade I: bleeds, no prolapse; II: prolapses and reduces spontaneously; III: needs manual reduction; IV: cannot be reduced | — |
| Treatment | Fiber, fluids, and topical care; office rubber band ligation for grades I–III; surgery for grade IV or failures | Conservative care; excision of a thrombosed hemorrhoid within about 72 hours of onset, otherwise sitz baths and analgesia |
Pregnancy and the postpartum period are peak times for hemorrhoids. Never attribute rectal bleeding to hemorrhoids without considering cancer: bleeding in patients 45 or older, or with red flags or bleeding mixed with stool, needs colonoscopy.
Dyspepsia, Peptic Ulcer Disease, and H. pylori
The two main causes of peptic ulcer disease are Helicobacter pylori and NSAIDs.
- Dyspepsia evaluation (ACG/CAG): Patients 60 or older with new dyspepsia generally have upper endoscopy; those under 60 are tested for H. pylori and treated if positive, with endoscopy for alarm features (bleeding, anemia, weight loss, dysphagia, persistent vomiting).
- Testing: Urea breath test or stool antigen; hold PPIs for 2 weeks and antibiotics or bismuth for 4 weeks first, because they cause false negatives. Serology cannot confirm active infection or cure.
- Treatment (ACG 2024): Bismuth quadruple therapy (PPI, bismuth subsalicylate, tetracycline, and metronidazole) for 14 days is preferred when susceptibility is unknown. Alternatives include rifabutin-based triple therapy and vonoprazan-amoxicillin dual therapy; clarithromycin triple therapy is used only when the strain is known to be clarithromycin-susceptible.
- Confirm eradication with a breath or stool test at least 4 weeks after treatment.
- NSAID ulcers: Stop the NSAID if possible; if NSAIDs must continue, add a PPI.
- In pregnancy, defer H. pylori eradication (tetracycline and bismuth are avoided) and manage symptoms with antacids, H2 blockers, or PPIs.
Inflammatory Bowel Disease
| Feature | Crohn Disease | Ulcerative Colitis |
|---|---|---|
| Distribution | Mouth to anus, skip lesions, often the terminal ileum | Continuous from the rectum proximally |
| Depth | Transmural: strictures, fistulas, perianal disease | Mucosal |
| Symptoms | Abdominal pain, diarrhea, weight loss, perianal fistulas | Bloody diarrhea, urgency, tenesmus |
Fecal calprotectin helps separate IBD from IBS, and colonoscopy with biopsy confirms the diagnosis. Reproductive counseling: Conceive during remission, because active disease raises the risk of miscarriage, preterm birth, and growth restriction. Continue most maintenance therapy (mesalamine, thiopurines, and anti-TNF biologics), but stop methotrexate at least 3 months before conception, and give folic acid 2 mg daily with sulfasalazine. Perianal Crohn disease affects delivery planning.
Celiac Disease
An immune reaction to gluten in genetically predisposed people (HLA-DQ2/DQ8), more common in women and in type 1 diabetes and autoimmune thyroid disease. Features include diarrhea or constipation, bloating, iron deficiency anemia, osteoporosis, elevated transaminases, dermatitis herpetiformis, and infertility or recurrent pregnancy loss. Screen with tissue transglutaminase IgA plus total IgA while the patient is eating gluten, and confirm with duodenal biopsy. Treatment is a lifelong gluten-free diet.
Diverticular Disease
Diverticulosis is common with age and usually asymptomatic; diverticular bleeding is painless. Acute diverticulitis causes left lower quadrant pain, fever, and leukocytosis, and is confirmed by CT. Uncomplicated diverticulitis in a healthy, immunocompetent outpatient can often be managed without antibiotics (AGA 2021, ACP 2022), with clear liquids and close follow-up. Complicated disease (abscess, perforation, obstruction) needs antibiotics, drainage, or surgery. Colonoscopy after recovery is advised if colon screening is not current.
Appendicitis in Pregnancy
Appendicitis is the most common nonobstetric surgical emergency in pregnancy. The appendix can shift upward as the uterus grows, so pain may be in the right flank or upper quadrant later in pregnancy. Use ultrasound, then MRI without gadolinium, and never delay surgery for diagnostic uncertainty, because perforation sharply raises the risk of fetal loss.
A 47-year-old woman reports intermittent bright red blood on toilet paper for 2 months. She has never had colorectal cancer screening, and anoscopy shows small grade I internal hemorrhoids. What is the most appropriate next step?
Attribute the bleeding to hemorrhoids and prescribe hydrocortisone suppositories for 2 weeks.
Perform office rubber band ligation and follow up only if bleeding persists after 1 year.
Prescribe a 14-day course of bismuth quadruple therapy for presumed peptic ulcer bleeding.
Arrange a colonoscopy, because bleeding at 45 or older without screening needs full evaluation.
A 35-year-old with 3 months of epigastric burning and no alarm features tests positive on a stool antigen test for Helicobacter pylori. She has no penicillin allergy, and local clarithromycin resistance is unknown. Which regimen is a preferred first-line treatment according to ACG 2024 guidance?
Bismuth quadruple therapy for 14 days
Omeprazole monotherapy for 8 weeks
Clarithromycin triple therapy for 7 days
High-dose amoxicillin alone for 10 days
A 29-year-old with Crohn disease in remission on adalimumab and low-dose methotrexate plans to conceive in 6 months. Which recommendation is most appropriate?
Stop adalimumab immediately because all biologic agents are teratogenic.
Stop methotrexate at least 3 months before conception and continue adalimumab.
Continue both drugs unchanged, because maintaining remission is the only priority.
Delay pregnancy until she has been off all IBD medications for at least 1 year.
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