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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