Constipation

Constipation is a common complaint that must be accurately defined by the patient before initiating an extensive evaluation. Constipation may include fewer than three bowel movements (BMs) in a week, excessive straining during BMs, a feeling of incomplete evacuation after BM, or passage of hard or pellet-like stools. The time of onset of constipation, amount of fluid and fiber in the diet, history of back trauma, neurologic problems, malignancy, medication history, and previous pattern of BMs may be helpful in reaching the correct diagnosis.

Differential Diagnosis

• 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)

Treatment

• If history, physical, and evaluation are all negative, a series of lifestyle modifications and conservative treatments are indicated
  –Increase fiber and fluid intake
  –Exercise
  –Avoid causative medications
  –Saline cathartics: Magnesium-containing compounds and phosphate enemas work by osmotic effect; avoid in renal insufficiency; for acute cases only
  –Hyperosmotic nonabsorbing sugars (e.g., lactulose) may be used for long-term management and are less toxic
  –Lavage solutions may be used for refractory constipation and impactions
  –Enemas: Low volume tap water or sodium phosphate (FLEET) may be used for severe constipation
  –A combination of suppositories (glycerin or bisaccodyl) and enemas (phosphate) will soften impactions; however, digital disimpaction may be necessary

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Pale stool

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Pale stool

• Back to symptom: Pale stool: Introduction (review 98 causes)
• Next Book Extract About Pale stool: Rectal Pain (In a Page: Signs and Symptoms)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Rectal Pain (In a Page: Signs and Symptoms)

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• Constipation (Handbook of Signs & Symptoms (Third Edition))

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