Diagnosis of Constipation
Diagnostic Test list for Constipation:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Constipation
includes:
Constipation Diagnosis: Book Excerpts
Tests and diagnosis discussion for Constipation:
Most people do not need extensive testing and
can be treated with changes in diet and exercise. For example, in young
people with mild symptoms, a medical history and physical examination may
be all the doctor needs to suggest successful treatment. The tests the
doctor performs depends on the duration and severity of the constipation,
the person's age, and whether there is blood in stools, recent changes in
bowel movements, or weight loss.
Medical History
The doctor may ask a patient to describe his or
her constipation, including duration of symptoms, frequency of bowel
movements, consistency of stools, presence of blood in the stool, and
toilet habits (how often and where one has bowel movements). Recording
eating habits, medication, and level of physical activity or exercise also
helps the doctor determine the cause of constipation.
Physical Examination
A physical exam may include a digital rectal
exam with a gloved, lubricated finger to evaluate the tone of the muscle
that closes off the anus (anal sphincter) and to detect tenderness,
obstruction, or blood. In some cases, blood and thyroid tests may be
necessary.
Extensive testing usually is reserved for people with severe symptoms,
for those with sudden changes in number and consistency of bowel movements
or blood in the stool, and for older adults. Because of an increased risk
of colorectal cancer in older adults, the doctor may use these tests to
rule out a diagnosis of cancer:
- Barium enema x-ray
- Sigmoidoscopy or colonoscopy
- Colorectal transit study
- Anorectal function tests.
Barium Enema X-Ray
A barium enema x-ray involves viewing the
rectum, colon, and lower part of the small intestine to locate any
problems. This part of the digestive tract is known as the bowel. This
test may show intestinal obstruction and Hirschsprung's disease, a lack of
nerves within the colon.
The night before the test, bowel cleansing, also called bowel prep, is
necessary to clear the lower digestive tract. The patient drinks 8 ounces
of a special liquid every 15 minutes for about 4 hours. This liquid
flushes out the bowel. A clean bowel is important, because even a small
amount of stool in the colon can hide details and result in an inaccurate
exam.
Because the colon does not show up well on an x-ray, the doctor fills
the organs with a barium enema, a chalky liquid to make the area visible.
Once the mixture coats the organs, x-rays are taken that reveal their
shape and condition. The patient may feel some abdominal cramping when the
barium fills the colon, but usually feels little discomfort after the
procedure. Stools may be a whitish color for a few days after the exam.
Sigmoidoscopy or Colonoscopy
An examination of the rectum and
lower colon (sigmoid) is called a sigmoidoscopy. An examination of the
rectum and entire colon is called a colonoscopy.
The night before a sigmoidoscopy, the patient usually has a liquid
dinner and takes an enema in the early morning. A light breakfast and a
cleansing enema an hour before the test may also be necessary.
To perform a sigmoidoscopy, the doctor uses a long, flexible tube with
a light on the end called a sigmoidoscope to view the rectum and lower
colon. First, the doctor examines the rectum with a gloved, lubricated
finger. Then, the sigmoidoscope is inserted through the anus into the
rectum and lower colon. The procedure may cause a mild sensation of
wanting to move the bowels and abdominal pressure. Sometimes the doctor
fills the organs with air to get a better view. The air may cause mild
cramping.
To perform a colonoscopy, the doctor uses a flexible tube with a light
on the end called a colonoscope to view the entire colon. This tube is
longer than a sigmoidoscope. The same bowel cleansing used for the barium
x-ray is needed to clear the bowel of waste. The patient is lightly
sedated before the exam. During the exam, the patient lies on his or her
side and the doctor inserts the tube through the anus and rectum into the
colon. If an abnormality is seen, the doctor can use the colonoscope to
remove a small piece of tissue for examination (biopsy). The patient may
feel gassy and bloated after the procedure.
Colorectal Transit Study
This test, reserved for those with
chronic constipation, shows how well food moves through the colon. The
patient swallows capsules containing small markers, which are visible on
x-ray. The movement of the markers through the colon is monitored with
abdominal x-rays taken several times 3 to 7 days after the capsule is
swallowed. The patient follows a high-fiber diet during the course of this
test.
Anorectal Function Tests
These tests diagnose constipation caused
by abnormal functioning of the anus or rectum (anorectal function).
Anorectal manometry evaluates anal sphincter muscle function. A catheter
or air-filled balloon inserted into the anus is slowly pulled back through
the sphincter muscle to measure muscle tone and contractions.
Defecography is an x-ray of the anorectal area that evaluates
completeness of stool elimination, identifies anorectal abnormalities, and
evaluates rectal muscle contractions and relaxation. During the exam, the
doctor fills the rectum with a soft paste that is the same consistency as
stool. The patient sits on a toilet positioned inside an x-ray machine and
then relaxes and squeezes the anus and expels the solution. The doctor
studies the x-rays for anorectal problems that occurred while the patient
emptied the paste.
(Source: excerpt from Constipation: NIDDK)
Diagnosis of Constipation: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Constipation:
Diagnostic Tests for Constipation: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Constipation.
CONSTIPATION:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the constipation acute or chronic? If the constipation is acute and there is abdominal pain or vomiting, one must consider the possibility of intestinal obstruction. An examination may disclose an empty rectum, in which case it is more likely complete intestinal obstruction, or there may be some feces in the rectum, in which case there may be incomplete intestinal obstruction. If the constipation is a chronic problem, one should investigate the patient's diet and emotional status and toilet habits over the life span.
- What kind of a diet is the patient on? Many patients today eat on the run, and they eat mostly fast foods, which are devoid of fiber. Frequently, they don't take the time to go to the bathroom. Some patients are on special diets to lose weight or have a fear of gaining weight; therefore, they don't eat well at all. If what the patient labels as constipation is simply infrequent bowel movements, but the bowel movements are normal in consistency, this is not really true constipation.
- Does the patient take drugs of any kind? Patients should be questioned first about chronic use of laxatives. Americans have the misconception that they must have a bowel movement every day and, therefore, they get in the habit of using something to stimulate the bowels, which can lead them to believe they have chronic constipation. Chronic narcotic use can lead to constipation, as can the use of antispasmodics for ulcer or urinary incontinence.
- Associated symptoms: We have already mentioned that abdominal pain and vomiting may be a sign of acute intestinal obstruction, and occasionally this is a sign of a chronic intestinal obstruction. If there is alternating diarrhea and constipation, one must consider the possibility of irritable bowel syndrome or a colon carcinoma. Blood in the stool along with painful defecation may indicate hemorrhoids and anal fissure. A person who is suffering from these conditions may delay moving his bowels for fear of the pain that accompanies this situation, and the hard stool that caused the hemorrhoids and anal fissure in the first place perpetuates the condition because it contributes to the constipation. If blood is found in the stool, well mixed with the stool, and defecation is basically painless, then colon carcinoma and diverticulitis must be considered. Blood and mucus in the stool would indicate an irritable bowel syndrome.
- What are the findings on physical examination? The finding of an empty rectum indicates an intestinal obstruction. A finding of an abdominal mass or a rectal mass certainly would indicate carcinoma of the colon. Rectal examination may disclose hemorrhoids or anal fissure as causing the chronic constipation and allow one to test the stool for occult blood.
DIAGNOSTIC WORKUP
If the constipation is acute, a flat plate of the abdomen and a CBC would be in order to determine if the patient has intestinal obstruction. The workup of chronic constipation should include stool for occult blood, sigmoidoscopy, barium enema, or a colonoscopy. A chemistry panel and other diagnostic studies may be necessary to rule out systemic causes of constipation such as diabetes, hypothyroidism, and various conditions associated with hypercalcemia. If diagnostic tests yield no positive findings, referral to a psychiatrist or a gynecologist may be in order. A trial of a fiber diet may be helpful. At the same time, one should eliminate chronic laxative usage. Anorectal manometry will help diagnose rectal and anal sphincter dysfunction. Defecography will help diagnose anorectal dysfunction also. A neurologist should be consulted if urinary retention is also a problem.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Constipation:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Medications
–Narcotic analgesics
–Antihypertensives (e.g., calcium channel blockers)
–Tricyclic antidepressants
–Aluminum hydroxide in antacids
–Iron supplements
-
Inadequate dietary fiber or liquid intake
-
Neurological dysfunction
–Diabetes mellitus
–Multiple sclerosis
–Hirschsprung's disease
-
Mechanical difficulties
–Colorectal cancer
–Hernia
–Diverticulitis
–Inflammatory bowel syndrome
–Adhesion
–Stricture
–Torsion
–Volvulus
-
Metabolic and endocrine
–Hypothyroidism
–Hypercalcemia
–Hypokalemia
-
Chronic laxative abuse
Workup and Diagnosis
- History and physical examination
–Specific attention to medication history, diet, and thyroid examination
–Abdominal examination: Note any surgical scars, palpate for masses (stool) and hepatosplenomegaly, check for hernias; however, note that examination results are often normal
–Rectal examination: Determine presence of stool, masses, hemorrhoids, fistulas, abscesses, or fissures; resting and squeezing sphincter tone; when patient bears down, relaxation of anal tone and perineal descents should be palpable (the absence of relaxation or inadequate perineal descents raises the suspicion of obstructive defecation)
-
Initial laboratory testing may include CBC, electrolytes, BUN/creatinine, glucose, calcium, phosphate, thyroid function tests, and fecal occult blood test
-
Consider a stool examination for ova and parasites, and flexible sigmoidoscopy or colonoscopy (colonoscopy if age greater than 50, new onset of constipation without cause, or blood in stool)
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Source: In a Page: Signs and Symptoms, 2004
Constipation:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Functional constipation
–By far the most common etiology
–Rome II criteria define chronic functional constipation in infants and young children as at least 2 weeks of scybalous, pebble-like, hard stools for the majority of stools, or firm stools two or fewer times per week
–Presents with stool-withholding behavior
–Often due to inadequate fluid/fiber intake
-
Drugs: Antacids (with aluminium and calcium), anticholinergics, antidepressants, bismuth, calcium antagonists, cough suppressants, opioid analgesics, phenobarbitol
-
Irritable bowel syndrome
-
Endocrine disorders
–Hypercalcemia
–Hypothyroidism
–Hyperparathyroidism
–Pregnancy
–Reduction of steroid hormones in luteal and follicular phases of menstrual cycle
-
Hirschsprung disease
–1/5,000 births, male to female ratio 4:1
–94% do not pass meconium within 24 hours of birth
–61% diagnosed by 12 months of life
-
Neurologic disease
–Myelomeningoce
–Hypotonia (e.g., Down, myopathies, prune-belly syndrome)
–Cerebral palsy
-
Celiac disease
-
Cystic fibrosis
-
Inflammatory bowel disease
-
Lead toxicity
- Structural abnormalities
–Anal disorders (imperforate anus, anteriorly displaced anus, perianal fissures, strep infection, anal stenosis)
–Colonic strictures (primary or secondary)
–Pelvic masses (sacral teratoma)
-
Infectious disease
–Infantile botulism
–Chagas disease
-
Metabolic disorders
–Uremia
–Hypokalemia
–Amyloid neuropathy
-
Ogilvie syndrome
Workup and Diagnosis
- History and physical exam are often diagnostic for functional constipation
- History
–Age at onset, duration, stool frequency/consistency, pain/bleeding with defecation, abdominal pain, toilet training, fecal soiling, stool-withholding behavior, appetite change, nausea/vomiting, weight loss, attempted treatments, dietary intake of fluid and fiber
–Medical history: Gestational age, time of meconium passage, existing medical conditions, surgeries, delayed growth and development, sensitivity to cold, coarse hair, medications, association with stress
-
Physical exam
–Vital signs (including growth parameters), abdominal exam for fecal mass, anal inspection (position of anus, soiling, sacral dimple, skin tags, perianal fissures; rectal examination: anal wink, anal tone, presence/consistency of stool, fecal mass, other masses, explosive stool on withdrawal of finger, occult blood), and neurologic examination (tone, strength, cremasteric reflex, DTRs)
-
KUB may demonstrate fecal mass in uncooperative patients
-
Labs rarely needed, but may include thyroid (TSH, free T4), electrolytes (including Ca++, Mg+++, Ph+++), lead level, and celiac testing (tissue transglutaminase IgA)
-
Rectal biopsy, manometry, or BE for Hirschsprung
-
Spinal MRI for sacral anomalies
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Source: In A Page: Pediatric Signs and Symptoms, 2007
CONSTIPATION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Rectal examination for a fecal impaction and subsequent enemas if no contraindication exists are the first steps. This may disclose a fissure, inflamed hemorrhoid, or abscess. Pelvic examination must be done in all females. If nothing is found here a proctoscopic examination and barium enema would be indicated, provided the neurologic examination and a flat plate of the abdomen are normal. Careful inquiry about diet, drugs, and emotional stress should be made.
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Source: Differential Diagnosis in Primary Care, 2007
Constipation:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has a physiological cause such as an anal or rectal disorder. In a patient older than age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation — extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with such disorders as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day's diet; estimate his daily fiber and fluid intake. Ask him about changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job and exercise pattern. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he's taking, including opioids and over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient's rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also, palpate for rectal masses and fecal impaction. Finally, obtain a stool sample and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as an acute intestinal obstruction and mesenteric artery ischemia, but it doesn't herald these conditions.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Constipation:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has an organic cause, such as an anal or rectal disorder. In a patient over age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation—extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens the pain, but in disorders such as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day’s menu; estimate his daily fiber and fluid intake. Ask him, too, about any changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he’s taking, including over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient’s rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also palpate for rectal masses and fecal impaction. Finally, obtain a stool specimen and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as acute intestinal obstruction and mesenteric artery ischemia, but it doesn’t herald these conditions.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Constipation:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The assessment and evaluation of the constipated patient begins with the history.
A. What is the patient’s description of the onset, duration, and frequency of constipation? Constipation of recent onset is suggestive of tumor.
B. Is rectal bleeding, melena, or narrowing of the stool caliber (all suggesting neoplasia) present (Chapter 9.11)?
C. What over-the-counter (OTC) medications are being used? (Is this patient potentially abusing OTC laxatives or taking OTC “cold” medicine containing an antihistamine?) Does the onset of constipation coincide with the taking of any of the medications listed in the MADE-O-FUN acrostic?
D. Does the past medical history, past surgical history, systems review, or chart review suggest any of the associated systemic illness listed in MADE-O-FUN? Is the patient known to have parkinsonism, renal failure, diabetes mellitus, hypertension (possibly treated with medications such as clonidine, calcium channel blockers, or potassium depleting diuretics, or other medications potentially causing decreased colonic tone), or hypothyroidism? Is there a history of cancer (potentially associated with hypercalcemia)?
Physical examination
Undertake a general physical examination looking for the stigmata of the associated constitutional illnesses mentioned in the MADE-O-FUN acrostic. Target the abdominal examination specifically for masses or abdominal tenderness and the rectal examination for fecal occult blood, rectal tone, rectal masses, rectal foreign body, impaction, anal fissure, hemorrhoids, or rectocoele—essential parts of the evaluation.
Diagnostic testing
Laboratory evaluation should consist of fecal occult blood testing (FOBT) looking for rectal bleeding; serum potassium and calcium to rule out hypokalemia and hypercalcemia (both associated with decreased colonic tone); serum glucose to evaluate possible diabetes; complete blood count looking for anemia (possibly related to chronic GI blood loss from tumor); blood urea nitrogen, serum creatinine, or both to rule out renal failure; and thyroid stimulating hormone to evaluate for hypothyroidism.
Visualize the lower colon via flexible sigmoidoscopy in patients aged more than 40 years whose constipation is of recent origin. Flexible sigmoidoscopy alone is insufficient for patients whose findings could suggest colonic neoplasia (melena, positive FOBT, hematochezia, abdominal mass, unexplained weight loss, or unexplained anemia). These patients should be offered either (a) colonoscopy or (b) barium enema plus flexible sigmoidoscopy.
Diagnostic assessment
The key diagnostic task in adults presenting with constipation is identifying those occasional patients whose constipation is caused by colorectal cancer. Because survival from colon cancer is directly related to the stage of the disease at time of diagnosis (3), patients whose history, examination, or laboratory findings are more suggestive of this diagnosis merit prompt investigation, including referral if necessary.
For patients whose constipation can be related to a particular systemic disease (e.g., hypercalcemia or hypothyroidism) or the use of particular medications (e.g., clonidine or an aluminum-containing antacid), identifying that link can be instrumental in ensuring that inciting issues are appropriately addressed in the management of the patient as a whole entity and not just as “a colon.”
In that greater host of patients whose initial evaluation suggests a more benign cause of constipation, or for whom constipation seems to be an incidental feature in an otherwise well individual, the decision to proceed with colonic visualization, or to begin a search for more unusual causes (the “U” in the MADE-O-FUN acrostic) will depend on the degree to which the constipation subjectively has an impact on the patient’s ability to live a fulfilling, happy, and rewarding life.
References
1. Drossman DA, McKee DC, Sandler RS, et al. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology 1982;83:529–534.
2. Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958–1986. Dig Dis Sci 1989;34:606–611.
3. Steele G. Colorectal cancer. In: Murphy GP, Lawrence W, Lenhad RE, eds. American Cancer Society textbook of clinical oncology, 2nd ed. Atlanta: The American Cancer Society, 1995:Chap 14.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Constipation:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Lifestyle
❑ Drugs
❑ Depression
❑ Irritable bowel syndrome
❑ Pelvic floor dysfunction
❑ Hypothyroidism
❑ Hypokalemia
❑ Colon cancer
❑ Anorectal pathology
❑ Voluntary retention
❑ Megacolon
❑ Mechanical obstruction
❑ Spinal cord pathology
❑ Hypercalcemia
❑ Scleroderma
Diagnostic Approach
Determine what the patient means by constipation. Patients are bothered by straining, excessively hard stools, unproductive urges, infrequency, and a feeling of incomplete evacuation.
With recent-onset constipation, seek an obstructing lesion, such as colon cancer, stricture, diverticular disease, inflammatory bowel disease, or foreign body. Hard stool in the vault rules out mechanical obstruction and suggests impaired emptying of the rectal vault. A change in stool caliber is more often caused by a tight sphincter than an “apple core” lesion.
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Source: Field Guide to Bedside Diagnosis, 2007
Chronic constipation:
Diagnosis
(Handbook of Diseases)
A patient history of dry, hard stool and infrequent bowel movements suggests chronic constipation due to an inactive colon. A digital rectal examination reveals stool in the lower portion of the rectum and a palpable colon. Analoscopy may show an unusually small colon lumen, prominent veins, and an abnormal amount of mucus. Diagnostic tests to rule out other causes include an upper GI series, barium enema, and examination of stool for occult blood from neoplasms.
Colonoscopy may be performed for inactive colon. Manometric studies may be done to exclude Hirschsprung’s disease, and internal and external sphincters may be evaluated.
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Source: Handbook of Diseases, 2003
Constipation:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he been constipated? Acute constipation usually has an organic cause, such as an anal or rectal disorder. In a patient over age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation — extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with disorders such as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day’s menu; estimate his daily fiber and fluid intake. Ask him, too, about any changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he’s taking, including over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Constipation:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Constitutional
Some children seem to have predispositionto passage of hard, infrequent bowel movements. Others have colonicinertia with delayed transit time and increased absorption of fluidin colon.
Dietary Factors
Inadequate fluid intake or high-protein dietwithout enough fiber are common factors predisposing to constipation.Undernutrition also may produce constipation.
Developmental, Situational, and Psychologic Disturbances
Often intertwineddevelopmental, situational, and psychologic factors may result in developmentof constipation. In such cases, stool pattern usually is normaluntil toilet training begins at 2–3 yrs. Excessive parentalconcern and forced attempts at defecation often cause conflict thatresults in fecal retention. Common response to negative toilet-trainingexperience or unresolved conflict between child and parent is withholdingof bowel movement.Purposefully avoiding bowel movementduring travel or while at school is another common cause.Stress that produces anxiety or depressionalso may produce constipation because of inability to attend toneed for defecation. Gastrointestinal Disorders
Anal Fissure
Tear in anal mucosa may contribute to constipationbecause children withhold stool rather than experience pain duringbowel movement. Fissures are readily seen on exam of anus.
Anal Stenosis
Less commonanatomic cause. Entire canal or any portion may be involved. Mayoccur in normal child or follow surgical repair of anal atresiaor other anorectal problems.Digital exam or endoscopy confirmsdiagnosis. Anterior Location of Anus
In thisunusual cause, anal opening is closer to vagina or scrotum thannormal.Diagnosis is made by visual inspection. Proctitis
Pain associatedwith proctitis may cause a child to withhold stool, so that constipation develops.Rectal trauma (foreign body) and sexualabuse are common causes of proctitis.History, physical exam, and proctoscopyare diagnostic. Congenital Aganglionic Megacolon (Hirschsprung Disease)
Absenceof ganglion cells in affected segment of intestine is responsiblefor this disorder. Delayed passage of meconium at birth is characteristic.Common manifestation is infrequentpassage of small, hard stools. Slow weight gain, abdominal distension,and empty ampulla on rectal exam are frequent findings.Suction rectal biopsy with acetylcholinesterasestaining can establish diagnosis. Otherwise, full-thickness rectalbiopsy sample that shows absence of ganglion cells is diagnostic.Manometric studies may help in somecases. Cystic Fibrosis
Childrenbeyond neonatal period may develop inspissation of intestinal contentsin terminal ileum, cecum, and proximal colon. Formerly called meconiumileus equivalent, this condition is now known as distal intestinalobstruction syndrome.Usual findings are vomiting, abdominalpain, and failure to pass bowel movements. Intestinal obstructionrequiring surgery may occur in some cases.See Chap.10, Cough, and Chap.14, Diarrhea. Celiac Disease
Althoughdiarrhea is usually the presenting symptom of celiac disease andoccurs in most cases, a few children may have constipation and markedabdominal distension.See Chap.14, Diarrhea. Chronic Intestinal Pseudoobstruction
Rare groupof familial and nonfamilial disorders of gastrointestinal smoothmuscle and enteric nervous system associated with ineffective intestinalmotility.Besides constipation, vomiting, crampyabdominal pain, and abdominal distension also may occur.See Chap.55, Regurgitation and Vomiting. Abdominal, Pelvic, and Sacral Masses
Large abdominal,pelvic, or sacral mass may compress colon and rectum and cause constipation.Besides abdominal exam, abdominal radiography,abdominal U/S, CT, and MRI are useful in locating and definingextent of mass.See Chap.1, Abdominal Masses. Neurologic Disorders
Neurologicallyimpaired children may have constipation because of difficulty in learningproper bowel control. Common example is mental retardation.Constipation also may be associatedwith spinal dysraphism, spinal cord injury, or spinal tumor becauseof damage to sensory and motor nerves in T12–S3 distribution.History and physical exam with absence of cremasteric reflex andanal wink along with poor rectal tone should suggest diagnosis.CT and MRI locate and define extent of lesions.Neuromuscular disorders (e.g., spinalmuscular atrophy, myasthenia gravis, muscular dystrophies, and infantbotulism) also may result in constipation.See Chap.33, Hypotonia and Weakness. Metabolic Disorders
Constipationmay occur with hypothyroidism and diabetes insipidus.See Chap.23, Growth Deficiency: Weight and Height, and Chap. 47, Polyuria and Polydipsia. Drugs
Some commonly used drugs that may produceconstipation include opioids, diuretics, anticholinergics, antacids(aluminum), phenytoin, and calcium channel blockers.
Diagnostic Approach
Diagnosisof many causes of constipation can be made by history and physicalexam.Age is a key factor. Although neonatesare more likely to have anatomic cause, most common causes in infantsand children are inadequate fluid and fiber in diet and combinationof developmental, situational, and psychologic factors.Physical exam is usually normal withmild constipation, whereas with severe constipation, stool is oftenpalpable in lower left quadrant and rectum is filled with hard feces.Abdominal radiograph shows presenceof stool, its extent, and whether lower spine is normal.If constipation fails to improve withusual therapy of adequate fluid intake, high-fiber diet, and laxatives,other disorders (e.g., congenital aganglionic megacolon) shouldbe suspected.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Constipation:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has a physiological cause such as an anal or rectal disorder. In a patient older than age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation—extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with such disorders as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day's diet; estimate his daily fiber and fluid intake. Ask him about recent changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also ask about his job and exercise pattern. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he's taking, including opioids and over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient's rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also palpate for rectal masses and fecal impaction. Finally, obtain a stool sample and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as an acute intestinal obstruction and mesenteric artery ischemia, but it doesn't herald these conditions.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
CONSTIPATION:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Rectal examination for a fecal impaction and subsequent enemas are the
first steps if no contraindication exists. This may disclose a fissure,
inflamed hemorrhoid, or abscess. Pelvic examination must be done in all
female patients. If nothing is found here a proctoscopic examination and
barium enema would be indicated, provided the neurologic examination and a
flat plate of the abdomen are normal. Careful inquiry about diet, drugs, and
emotional stress should be made.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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