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Constipation

Overview

  • Constipation is commonly a result of poor diet and sedentary lifestyle, however it may also signal underlying gastrointestinal or non-gastrointestinal pathology. History-taking can aid in dividing these differential diagnoses and narrowing in on a cause.

Aetiology

    • Causes of Constipation

    • Primary

    • Functional Constipation

    • Colorectal

    • Faecal impaction
    • Colorectal cancer
    • Strictures - diverticular disease, ischaemia, IBD, radiation
    • Volvulus
    • Prolapse - rectocoele, enterocoele
    • Anorectal disorders - fissure, fistula, ulcer, large haemorrhoids
    • Motility disorders - slow transit bowel, irritable bowel syndrome

    • Non-Colorectal

    • Lifestyle factors - poor diet, physical inactivity, increased age
    • Medications - opioids, NSAIDs, ondansetron, anticholinergics, diuretics, antiepileptics, antacids, iron supplements, calcium supplements, calcium channel blockers
    • Metabolic / endocrine - hypercalcaemia, hypokalaemia, uraemia, diabetes, hypothyroidism
    • Neurological - stroke, Parkinson’s disease, MS, spinal cord trauma, Hirschprung disease
    • Connective tissue disorders - amyloidosis, scleroderma
    • Psychogenic - anxiety, depression, anorexia nervosa
    • Pregnancy

History of Presenting Complaint

    • Stools

      • The colour and consistency of the patient's stools.

    • Onset

      • Whether the constipation started suddenly or gradually, and in what situation.

    • Timing

      • Frequency of stools, and whether the patient passes any normal  or loose stools between episodes of constipation.

    • Associated Symptoms

      Whether the constipation is associated with any other symptoms.
    • Abdominal painNonspecific feature of many GI causes
    • Sharp anorectal pain on passing stoolsSuggestive of anal fissure
    • Abdominal BloatingSuggestive of irritable bowel syndrome
    • Blood stained stoolsRed flag for colorectal cancer, diverticulitis or IBD
    • Blood on toilet paperSuggestive of haemorrhoids or anal fissure
    • Episodes of incontinenceSuggestive of overflow incontinence secondary to obstruction
    • Weight lossRed flag for colorectal cancer
    • Faeculant vomitingSerious indicator of bowel obstruction

    • Exacerbating Factors

      • Whether there is anything that makes the consipation worse.

    • Alleviating Factors

      • Whether there is anything that improves the constipation, and whether they have had any improvement with apperients.

Extra Credit

  • The Rome III criteria are used for the diagnosis of functional constipation. The criteria must be present for the last three months, with symptom onset at least 6 months prior to diagnosis.

    • Rome III Criteria

    • Diagnostic Criteria - ≥2 present

    • Straining while defaecating at least 25% of defaecations
    • Lumpy or hard stools at least 25% of defaecations
    • Sensation of incomplete evacuation for at least 25% of defaecations
    • Sensation of anorectal obstruction or blockage for at least 25% of defaecations
    • Need for digital maneuvers to evacuate stool at least 25% of defaecations
    • Less than three defaecations per week

    • Additional Criteria

    • Loose stools rarely present without the use of laxatives
    • Insufficient criteria to indicate irritable bowel syndrome
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Associated Diseases
BETA

Gastrointestinal
Inflammatory Bowel Disease
Radiation Colitis
Diverticular Disease
Volvulus
Constipation
Anal Fistula
Perianal Ulcer
Perianal Abscess
Haemorrhoids
Rectal Prolapse
Radiation Proctitis
Mesenteric Ischaemia
Irritable Bowel Syndrome
Neurological
Ischaemic Stroke
Subarachnoid Haemorrhage
Intracerebral Haemorrhage
Multiple Sclerosis
Spinal Cord Neoplasia
Nutrition & Metabolic
Amyloidosis
Hypercalcaemia
Familial Hypocalciuric Hypercalcaemia
Hypercalcaemia of malignancy
Psychiatry
Major Depressive Disorder
Generalised Anxiety Disorder
Anorexia Nervosa
Other
Hypothyroidism
Scleroderma
Normal Pregnancy
Colorectal Cancer
Anal Cancer
Hirschprung's Disease
Uraemia

Associated Drugs
BETA

Cardiovascular
QuinidineProcainamide
Calcium Channel Blockers
Spironolactone
Loop Diuretics
Hydrochlorothiazide
Psychiatric
Monoamine Oxidase Inhibitors
Amitriptyline
Antipsychotics
Other
Analgesic Agents
Opioids
Drug & Alcohol
Atropine
Endocrine
Teriparatide
Gastrointestinal
ProchlorperazineOndansetron
Immunology
Basiliximab
Infectious Diseases
M2 Inhibitors
Oncology
Vinca Alkaloids
Anti-EGFR (HER1)
Psychiatry
Doxepin
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