Constipation

Group 5
Causes of Constipation
• Lack of adequate dietary fiber in diet.1
• Lack of adequate water intake1
• Lack of physical activity to stimulate bowel movement.1
• Medications e.g. narcotics, NSAIDs, muscle relaxants, tricyclic
antidepressants, urinary incontinence drugs, iron supplements, blood
pressure medications, anti-nausea drugs etc.2
• Ignoring or delaying the urge to defecate.1
• Irritable bowel syndrome.1
Causes of constipation
• Mechanical obstruction of the colon or rectum like colon cancer, adhesions from
previous surgeries, megacolon (hirschsprung’s disease), pelvic floor dysnergia,
Diverticulosis, rectal prolapse etc.1
• Neurologic disorders like traumatic brain injuries, stroke, spinal cord injury,
aganglionosis etc.1
• Myopathies e.g. multiple sclerosis, Parkinson’s disease, cerebral palsy etc. 1
• Metabolic and endocrine disorders e.g. hypothyroidism, diabetes,
hypercalcemia, hypokalemia etc.1
• Psychological: stress, depression, anxiety based on change in environment,
previous trauma/abuse etc.3
• It can be idiopathic in some people.1
History taking
• A good and proper history should be taken
• Presenting complaint: infrequent passage of stool (less than 3 times a week)4
• History of presenting complaint: frequency, nature and consistency of stool, pain on defecation,
straining or discomfort, recent change in bowel habit, constipation alternating with diarrhea, any
associated blood or mucus, sensation of incomplete emptying on defecation, abdominal pain,
distensions, cramps.4
• Past medical history: previous bowel surgery, inflammatory bowel disease, any medical condition.4
• Drug history: are they on any routine medications? Any known allergies?4
• Family history: any history colorectal cancer or history of chronic constipation in family members?4
• Social history: diet, smoking, psychological history4
• The patient should also be asked to describe the stool caliber. The Bristol Stool Scale is a useful tool
to assess stool type and to tailor and monitor treatment. (types 1 & 2 indicates constipation, 3-4
“ideal stool”, 5-7 tending towards diarrhea or urgency).5
Stool caliber
Investigations
• Physical examination: lymphadenopathy, abdominal mass, anemia, would be suspicious of
colorectal cancer.4
• A digital rectal examination is essential. Fissures/hemorrhoids. Impacted stools, blood/mucus
should be watched out for.4
• Other examinations include:
• Blood tests: full blood count, calcium, E/U/Cr, thyroid function tests.4
• Abdominal x-ray: mostly done to rule out obstruction.4
• CT scan of abdomen.4
• Colonoscopy and biopsies4
• Barium enema4
• Bowel transit studies4
• Behavioral therapy4
Investigation
• Sitmaz test: this helps to measure the time it takes for food to travel
down the gut. This is done by giving tiny soft rubber rings in a capsule
to be swallowed and then an x-ray is taken days later to see how
many rings are left.6
• Anorectal mamometry: this is used to measure the pressure in the
anal canal when you have to strain to defecate6
• Pelvic floor electromyography.6
• Balloon defecation6
• Evacuation defecography6
Diagnosis (Rome IV criteria)
• You must have 2 or more of the following symptoms over the preceding three months 3:
• The passage of hard, lumpy, pellet-like stools.
• Straining for more than 25%of defecation attempts.
• Sensation of anorectal obstruction or blockage for at least 25% of defecation attempts.
• A sense of incomplete emptying of the rectum with a bowel movement 25% of
defecation attempts.
• Loose stools are rarely present without the use of enemas, suppositories, oral laxatives.
• Manual maneuvers such as digital stimulation or pelvic floor support are needed for
25% of defecation attempts.
• Fewer than three 3 bowel movements per week.
• Insufficient criteria for irritable bowel syndrome.
References
1. Constipation.pdf. (Terri O’Neill RN, BSN, University of Michigan, Constipation, last
reviewed 03/21
2. 8 medications that cause constipation [Internet]. The Checkup. 2020 [cited 2021 Nov 9].
Available from: https://www.singlecare.com/blog/medications-that-cause-constipation/
3. Constipation: Practice Essentials, Background, Pathophysiology. 2021 Oct 17 [cited 2021
Nov 9]; Available from: https://emedicine.medscape.com/article/184704-overview#a1
4. Constipation - Oxford Medical Education [Internet]. [cited 2021 Nov 11]. Available from:
https://oxfordmedicaleducation.com/gastroenterology/constipation/
5. Bristol Stool scale: Stool types and what they mean [Internet]. 2021 [cited 2021 Nov 11].
Available from: https://www.medicalnewstoday.com/articles/bristol-stool-scale
6. Whitehead WE, Co-Director C. COMPREHENSIVE OVERVIEW OF CONSTIPATION. :3.