constipation

Dr.Luqman Rahman

8/1/2022
Case study
• 46 yrs old woman comes to the general hospital seeking medical
attention for her constipation.
• She is not known to have any comorbid conditions.
• Not smoker, not alcoholic.
• Married and has three children. House wife, not employed.
Constipation
• persistent, difficult, infrequent, or seemingly incomplete defecation.
Chronic Constipation
Is it common?
One of the most common chronic gastrointestinal disorders in adults.
Constipation compromises quality of life, social functioning, and the
ability to perform activities of daily living.
is three times higher in women and women are twice as likely as men
to schedule physician visits for constipation
• prevalence peaks after 70 years of age, reaching between 8 and 43
percent, depending on the population studied.
 Types of Constipation
Functional (primary)
Secondary
Functional (primary)
786 • GASTROENTEROLOGY

Psychosocial Neurodegenerative
Deprivation, starvation Parkinsonism
Eating disorders Dementia
Depression, bipolar illness Motor neuron disease
Bereavement
Chronic pain/sleep Endocrine
deprivation Type 1 diabetes
Alcoholism Thyrotoxicosis
Addison’s disease
Respiratory
Chronic obstructive pulmonary disease
Pulmonary tuberculosis
Occult malignancy (especially Cardiac
small-cell carcinoma)
Congestive cardiac failure
Empyema
Infective endocarditis
Gastrointestinal
Poor dentition Renal
Any cause of oral pain, Occult malignancy
dysphagia Chronic renal failure
Malabsorption Salt-losing
Malignancy at any site nephropathy
Inflammatory bowel disease
Chronic infection
Cirrhosis

Chronic infection Rheumatological

HIV/AIDS Rheumatoid arthritis
Tuberculosis Mixed connective tissue disease
Brucellosis Systemic sclerosis
Gut infestations Systemic lupus erythematosus

Fig. 21.24 Some important causes of weight loss.

Investigations
21.20 Causes of constipation
In cases where the cause of weight loss is not obvious after
thorough history taking and physical examination, or where an Gastrointestinal causes
existing condition is considered unlikely, the following investigations Dietary
are indicated: urinalysis for glucose, protein and blood; blood tests, • Lack of fibre and/or fluid intake
including liver function tests, random blood glucose and thyroid
Motility
function tests; CRP and ESR (may be raised in unsuspected • Slow-transit constipation • Chronic intestinal
infections, such as tuberculosis, connective tissue disorders • Irritable bowel syndrome pseudo-obstruction
and malignancy); and faecal calprotectin. Sometimes invasive • Drugs (see below)
tests, such as bone marrow aspiration or liver biopsy, may be Structural
necessary to identify conditions like cryptic miliary tuberculosis • Colonic carcinoma • Hirschsprung’s disease
(p. 588). Rarely, abdominal and pelvic imaging by CT may • Diverticular disease
be required, but before embarking on invasive or very costly Defecation
investigations it is always worth revisiting the patient’s history • Anorectal disease (Crohn’s, • Obstructed defecation
and reweighing at intervals. fissures, haemorrhoids)
Non-gastrointestinal causes
Constipation Drugs
• Opiates • Iron supplements
Constipation is defined as infrequent passage of hard stools. • Anticholinergics • Aluminium-containing antacids
Patients may also complain of straining, a sensation of incomplete • Calcium antagonists
evacuation and either perianal or abdominal discomfort. Neurological
Constipation may occur in many gastrointestinal and other • Multiple sclerosis • Cerebrovascular accidents
• Spinal cord lesions • Parkinsonism
medical disorders (Box 21.20).
Metabolic/endocrine
Clinical assessment and management • Diabetes mellitus • Hypothyroidism
• Hypercalcaemia • Pregnancy
The onset, duration and characteristics are important; for example,
a neonatal onset suggests Hirschsprung’s disease, while a recent Others
change in bowel activity in middle age should raise the suspicion of • Any serious illness with • Depression
immobility, especially in the
an organic disorder, such as colonic carcinoma. The presence of
elderly
rectal bleeding, pain and weight loss is important, as are excessive
Calcium-channel blockers, such as diltiazem (Cardizem). These drugs relax the
smooth muscles in blood vessels to lower blood pressure. But they also relax the
muscles in the gut and may cause constipation
 Presenting problems in gastrointestinal disease • 787
straining, symptoms suggestive of irritable bowel syndrome, a
history of childhood constipation and emotional distress.
Careful examination contributes more to the diagnosis than
extensive investigation. A search should be made for general
medical disorders, as well as signs of intestinal obstruction.
Neurological disorders, especially spinal cord lesions, should be
sought. Perineal inspection and rectal examination are essential
and may reveal abnormalities of the pelvic floor (abnormal
descent, impaired sensation), anal canal or rectum (masses,
faecal impaction, prolapse).
It is neither possible nor appropriate to investigate every
person with constipation. Most respond to increased fluid intake,
dietary fibre supplementation, exercise and the judicious use of
laxatives. Middle-aged or elderly patients with a short history or
worrying symptoms (rectal bleeding, pain or weight loss) must be
investigated promptly, by either barium enema or colonoscopy.
For those with simple constipation, investigation will usually
proceed along the lines described below.
Initial visit
Digital rectal examination, proctoscopy and sigmoidoscopy (to
detect anorectal disease), routine biochemistry, including serum
calcium and thyroid function tests, and a full blood count should
be carried out. If these are normal, a 1-month trial of dietary
fibre and/or laxatives is justified.
Next visit
If symptoms persist, then examination of the colon by barium enema
or CT colonography is indicated to look for structural disease.
Further investigation
If no cause is found and disabling symptoms are present, then
specialist referral for investigation of possible dysmotility may
be necessary. The problem may be one of infrequent desire to
defecate (‘slow transit’) or else may result from neuromuscular
incoordination and excessive straining (‘functional obstructive
defecation’, p. 803). Intestinal marker studies, anorectal
manometry, electrophysiological studies and magnetic resonance
proctography can all be used to define the problem.
Abdominal pain
There are four types of abdominal pain:
• Visceral. Gut organs are insensitive to stimuli such as
burning and cutting but are sensitive to distension,
contraction, twisting and stretching. Pain from unpaired
structures is usually, but not always, felt in the midline.
• Parietal. The parietal peritoneum is innervated by somatic
nerves and its involvement by inflammation, infection or
neoplasia causes sharp, well-localised and lateralised pain.
• Referred pain. Gallbladder pain, for example, may be
referred to the back or shoulder tip.
• Psychogenic. Cultural, emotional and psychosocial factors
influence everyone’s experience of pain. In some patients,
no organic cause can be found despite investigation, and
psychogenic causes (depression or somatisation disorder)
may be responsible (pp. 1198 and 1202).
The acute abdomen
This accounts for approximately 50% of all urgent admissions
to general surgical units. The acute abdomen is a consequence
of one or more pathological processes (Box 21.21):
• Inflammation. Pain develops gradually, usually over several
hours. It is initially rather diffuse until the parietal
21.21 Causes of acute abdominal pain
Inflammation
• Appendicitis • Pancreatitis
• Diverticulitis • Pyelonephritis
• Cholecystitis • Intra-abdominal abscess
• Pelvic inflammatory disease
Perforation/rupture
• Peptic ulcer • Ovarian cyst
• Diverticular disease • Aortic aneurysm
Obstruction
• Intestinal obstruction • Ureteric colic
• Biliary colic
Other (rare)
• See Box 21.23
peritoneum is involved, when it becomes localised.
Movement exacerbates the pain; abdominal rigidity and
guarding occur.
• Perforation. When a viscus perforates, pain starts abruptly;
it is severe and leads to generalised peritonitis.
• Obstruction. Pain is colicky, with spasms that cause the
patient to writhe around and double up. Colicky pain
that does not disappear between spasms suggests
complicating inflammation.
Initial clinical assessment
If there are signs of peritonitis (guarding and rebound tenderness
with rigidity), the patient should be resuscitated with oxygen,
intravenous fluids and antibiotics. In other circumstances, further
investigations are required (Fig. 21.25).
Investigations
Patients should have a full blood count, urea and electrolytes,
glucose and amylase taken to look for evidence of dehydration,
leucocytosis and pancreatitis. Urinalysis is useful in suspected 21
renal colic and pyelonephritis. An erect chest X-ray may show
air under the diaphragm, suggestive of perforation, and a plain
abdominal film may show evidence of obstruction or ileus (see
Fig. 21.11). An abdominal ultrasound may help if gallstones
or renal stones are suspected. Ultrasonography is also useful
in the detection of free fluid and any possible intra-abdominal
abscess. Contrast studies, by either mouth or anus, are useful
in the further evaluation of intestinal obstruction, and essential
in the differentiation of pseudo-obstruction from mechanical
large-bowel obstruction. Other investigations commonly used
include CT (seeking evidence of pancreatitis, retroperitoneal
collections or masses, including an aortic aneurysm or renal
calculi) and angiography (mesenteric ischaemia).
Diagnostic laparotomy should be considered when the
diagnosis has not been revealed by other investigations. All
patients must be carefully and regularly re-assessed (every
2–4 hours) so that any change in condition that might alter both
the suspected diagnosis and clinical decision can be observed
and acted on early.
Management
The general approach is to close perforations, treat inflammatory
conditions with antibiotics or resection, and relieve obstructions.
The speed of intervention and the necessity for surgery depend
on the organ that is involved and on a number of other factors,
Colorectal Cancers
• Incidence? How common it is?
• Increasing vs decreasing?? How? And why??
Colorectal Cancers
• Most colorectal cancers, regardless of etiology, arise from
adenomatous polyps.
• Only adenomas are clearly premalignant, and only a minority of
adenomatous polyps evolve into cancer.
• ~30% of middle-aged and ~50% of elderly people; however, <1% of
polyps ever become malignant.
• Occult blood in the stool is found in <5% of patients with polyps
Types of polyps
Histologically, adenomatous polyps may be tubular, villous (i.e., papillary), or tubulovillous. Villous
adenomas, most of which are sessile, become malignant more than three times as often as tubular
adenomas. 
• The likelihood that any polypoid lesion contains invasive cancer is
related to the size of the polyp, being negligible (<2%) in lesions <1.5
cm, intermediate (2–10%) in lesions 1.5–2.5 cm, and substantial (10%)
in lesions >2.5 cm in size.

• synchronous lesions are noted in

about one-third of cases
•
Colorectal Polyps
• Adenomatous polyps are thought to require >5 years of growth
before becoming clinically significant;
• colonoscopy need not be carried out more frequently than every 3
years for the vast majority of patients.
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• Aspirin
• Vitamin D
• Estrogen
Screening
• About 50% of patients with documented colorectal cancers have a
negative fecal occult blood test.
• CRC have been found in <10% of these “test-positive” cases, with
benign polyps being detected in an additional 20–30%.
• FOB testing annually coupled with flexible sigmoidoscopy every 5
years or colonoscopy every 10 years beginning at age 50 in
asymptomatic individuals with no personal or family history of polyps
or colorectal cancer.
• ~21% reduction in the development of colorectal cancer and a >25%
reduction in mortality from the malignant disease
All of the followings are recognized causes of secondary
constipation, except:

A. Hypothyroidism

B. Hypercalcemia

E. Opiates

C. Hypokalemia

D. Bulking agents

Answer: d
Regarding functional (primary) constipation:

A. Usually caused by metabolic disorders

B. More common in women

C. Pelvic floor dysfunction is the commonest subtype

D. Surgery offers the best option of cure

E. Usually acute in nature

Answer: b
Colorectal Polyps:

A. Regarded as premalignant conditions

B. Can be treated by NSAID

C. Risk is not related to the type and the size of the polyp

D. All proceed to malignancy if not treated

E. Commonly detected in children

Answer: a
Regarding colorectal cancers:

A. Female to Male ratio is 5.1

B. The incidence is dropping dramatically.

C. Intestinal obstruction is an early feature.

D. Usually presented with B12 deficiency anemia.

E. Bleeding per rectum and altered bowel habits are the

commonest complaints.

Answer: e