5/9/23, 3:24 AM Constipation - MRCEM Success

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Constipation
Gastroenterology &
Hepatology
MRCEM Success

USEFUL LINKS
 NICE CKS

CURRICULUM CODE
GP4 Constipation
GP2 Abdominal Swelling and Mass
SuP2 Abdominal Swelling and Mass
SuP3 Constipation

KEYWORDS

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Constipation

RELATED TOPICS
Gastroenterology & Hepatology
Surgical Emergencies

Something wrong?

Constipation LAST UPDATED: 4TH

AUGUST 2022
GASTROENTEROLOGY & HEPATOLOGY /
SURGICAL EMERGENCIES  Bookmark

Constipation is unsatisfactory defecation because of infrequent stools, difficult stool

passage, or the sensation of incomplete emptying. Stools are often dry and hard or lumpy,
and may be abnormally large or small.
Chronic constipation usually describes symptoms which are present for at least 12 weeks in
the preceding six months. Faecal loading/impaction is retention of faeces to the extent that
spontaneous evacuation is unlikely. Overflow incontinence is leakage of liquid stool from the
proximal colon around impacted faeces.

Causes
Risk factors for developing constipation include:
Social
Low fibre diet or low calorie intake
Lack of exercise or reduced mobility
Difficult access or privacy to the toilet
Psychological
Eating disorders
History of sexual abuse
Anxiety or depression
Physical
Female sex
Older age
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Pyrexia, dehydration, immobility

Secondary causes of constipation:
Drugs
Endocrine/metabolic causes
Diabetes mellitus (with autonomic myopathy)
Hypercalcaemia/hypermagnesaemia
Hypokalaemia
Hypothyroidism
Uraemia
Myopathic causes
Amyloidosis
Myotonic dystrophy
Scleroderma
Neurological causes
Autonomic neuropathy
Cerebrovascular disease
Multiple sclerosis
Parkinson’s disease
Spinal cord injuries
Structural abnormalities
Anal fissures
Haemorrhoids
Colonic strictures
Inflammatory bowel disease
Diverticular disease
Obstructive colonic mass lesions
Rectal prolapse or rectocele

Complications
Complications of chronic constipation include:
Haemorrhoids or anal fissure.
Progressive faecal retention, distension of the rectum, and loss of sensory and
motor function.
Faecal loading and impaction.
Complications of chronic faecal loading and impaction include:
Faecal incontinence, which can be embarrassing and distressing.
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Chronic dilatation of the colon may cause megacolon.

Bowel obstruction, perforation, or ulceration.
Recurrent urinary tract infections, obstructive uropathy.
Rectal bleeding.
Rectal prolapse.

Diagnosis
Suspect a diagnosis of constipation if an adult presents with defecation which is
unsatisfactory because of infrequent stools, difficulty passing stools, or a sensation of
incomplete emptying. Additional symptoms may include lower abdominal pain or
discomfort, distension, or bloating.
Consider a diagnosis of constipation in the elderly if there are non-specific symptoms, such
as:
Confusion or delirium, functional decline.
Nausea or loss of appetite.
Overflow diarrhoea.
Urinary retention.
Suspect a diagnosis of faecal loading or impaction if there is history of:
Hard, lumpy stools, which may be large and infrequent (for example passed every 7–10
days), or small and relatively frequent (for example passed every 2–3 days).
Having to use manual methods to extract faeces.
Overflow faecal incontinence, or loose stool.
Examine the patient:
Assess for signs of weight loss and general nutritional status.
Perform an abdominal examination to check for abdominal pain, distension, masses,
or a palpable colon (suggesting retained faecal masses).
Perform an internal rectal examination, checking for:
Anal fissures, haemorrhoids, skin tags, rectal prolapse, rectocele, skin erythema
or excoriation (may be a sign of faecal leakage).
Resting anal sphincter tone; rectal mass lesions and retained faecal masses,
which may also be felt on external peri-anal palpation. Note: a faecal mass can
be distinguished from a tumour or cyst, as firm pressure exerted by a finger will
typically leave a palpable indentation in hard faeces.
Pelvic floor dysfunction (if appropriate) — while asking the person to 'bear
down', there may be paradoxical contraction of the anal sphincter on straining.
Leakage of stool; rectal or anal pain.
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Management
Treat faecal loading and/or impaction
For hard stools, consider using a high dose of an oral macrogol
For soft stool (or ongoing hard stools after treatment with macrogol) consider
starting or adding an oral stimulant laxative e.g. bisacodyl, senna or glycerol
If response to oral laxatives is insufficient or too slow consider using a
suppository e.g. bisacodyl +/- glycerol, a mini-enema e.g. docusate, sodium
citrate
If the response to treatment is still inadequate, consider prescribing a sodium
phosphate retention enema
Advice about increasing dietary fibre, drinking an adequate fluid intake and exercising
If laxatives are required:
Start with bulk-forming laxatives e.g. ispaghula husk (except in opioid-induced
constipation)
If stools remain hard, add or switch to an osmotic laxative e.g. macrogol or
lactulose
If stools are soft, but still difficult or pass or empty inadequately, add a stimulant
laxative

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