Abstract
<title>Abstract</title> <p>Background Constipation is among the most common gastrointestinal disorders and is generally managed as a benign condition in ambulatory settings. However, refractory disease in vulnerable populations can initiate a severe pathophysiologic cascade— fecal impaction, stercoral colitis, colonic perforation, and sepsis with case-fatality as high as 22% once stercoral colitis develops. Despite these risks, national epidemiologic trends in constipation-associated mortality remain largely unmapped. Methods We performed a serial cross-sectional analysis of the CDC WONDER Multiple Cause of Death (MCD) database for U.S. adults aged ≥ 25 years. Constipation-associated deaths were identified by ICD-10 code K59.0 listed as an underlying or contributing cause. Primary trend estimation relied on final mortality data from 1999 through 2024. We evaluated provisional 2025 data in a secondary capacity. Age-adjusted mortality rates (AAMRs) per 100,000 (2000 U.S. standard population) were analyzed by sex, age, race/ethnicity, urbanization, census region, state, and place of death. Temporal trends were quantified by Joinpoint regression (annual and average annual percentage change [APC/AAPC]). We additionally contrasted multiple-cause with underlying-cause mortality and tested whether co-coded psychoactive substance use disorders (ICD-10 F10–F19) accounted for the trend. Results From 1999–2024, 22,237 constipation-associated deaths were recorded (23,946 including provisional 2025). The overall AAMR rose from 0.26 (95% CI 0.23–0.28) in 1999 to 0.55 (0.53–0.58) in 2024 (AAPC 2.68; 95% CI 2.10–3.26; P < 0.001), remaining stable through 2012 and then increasing (2012–2024 APC 4.90; 4.14–5.66); including provisional 2025, the AAMR reached 0.64 (AAPC 2.80; 2012–2025 APC 5.02). Constipation was recorded as a contributing cause approximately 5- to 7-fold more often than as the underlying cause (underlying-cause AAMR 0.05→0.09; AAPC 1.08, P = 0.18). The burden was concentrated among adults ≥ 65 years (mean AAMR 1.66 vs 0.12 at 45–64 years), women (0.39 vs 0.33), non-metropolitan residents (0.43 vs 0.31), and the West (0.44). Nearly three-quarters of deaths occurred in hospitals (47.4%) or nursing/long-term-care facilities (24.7%). Co-coded psychoactive substance use disorders plateaued after 2012 and were dominated by alcohol and tobacco; opioid-specific co-coding accounted for < 1% of deaths, indicating that the post-2012 increase was not attributable to psychoactive substances. Conclusions While absolute rates remain low, constipation-associated mortality has increased significantly since 2012. The burden falls disproportionately on older adults, women, and those residing in non-metropolitan areas or institutional settings. The pronounced disparity between contributing-cause and underlying-cause mortality confirms that severe constipation exerts its fatal effect indirectly through downstream sequelae rather than as a primary terminal event. Early recognition and protocolized bowel care in high-risk inpatient and long-term-care settings are warranted. Clinical Trial Registration not applicable</p>