Forensic considerations in cases of fatal constipation

Constipation is characterized by persistent difficulty in defecating. It is a common disorder in the community particularly affecting the elderly and those with intellectual disabilities and neuropsychiatric disorders. It is also caused by numerous medications including analgesic, antidepressant, antihypertensive and anticholinergic agents. It may be asymptomatic or it may produce abdominal pain/cramps, bloating, nausea and anorexia progressing to urinary incontinence and fecal impaction, or paradoxical diarrhea due to overflow. A wide range of mechanisms associated with constipation may result in death including bowel obstruction, stercoral colitis with ulceration, perforation and peritonitis, respiratory compromise, abdominal compartment syndrome and venous thrombosis with pulmonary thromboembolism. Constipation may exacerbate pre-existing diseases and treatments such as laxative and enemas may be lethal. The autopsy examination of a case with constipation and megacolon should take into account all of the pre-existing conditions, as well as the possibility of underlying disorders such as Hirschprung disease. Review of the decedent's medical and drug history and level of supportive care will be important. Toxicological evaluations may be useful.