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Constipation
Constipation is a symptom not a diagnosis and means different things to different people. Always ask patients exactly what they mean by the term constipation. There are various formal (and different) definitions of constipation. It is defined as defecation that is unsatisfactory because of infrequent stools (<3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.1
Patients may mean that:
- Faeces are too hard
- They do not defecate often enough for 'inner cleanliness'
- Defecation hurts
- They have diarrhoea.
A careful history helps to determine the possible cause. Ask about frequency, nature and consistency of the stool. Is there blood or mucus in/on the stools? Is there diarrhoea alternating with constipation? Has there been a recent change in bowel habit? Ask about diet and drugs.
Rectal examination is essential.
| Causes of constipation | |
|---|---|
| Common Causes | Low fibre diet Inadequate fluid intake or dehydration Immobility (or lack of exercise) Irritable bowel syndrome Old age Post-operative pain Hospital environment (lack of privacy, having to use a bed pan) |
| Anorectal Disease | Anal fissure Anal stricture (See Around the anus) Rectal prolapse |
| Intestinal Obstruction | Strictures (eg Crohn's disease) Colorectal carcinoma Pelvic mass (eg fetus, fibroids) Diverticulosis (rectal bleeding is a commoner presentation) Congenital abnormalities Pseudo-obstruction |
| Metabolic / endocrine | Hypothyroidism Hypercalcaemia Hypokalaemia Porphyria Lead poisoning |
| Drugs | Opiate analgesics (eg morphine, codeine) Anticholinergics (tricyclics, phenothiazines) Iron |
| Neuromuscular | Spinal or pelvic nerve injury Aganglionosis (Chagas' disease, Hirschsprung's Disease) Systemic sclerosis Diabetic neuropathy |
| Other Causes | Chronic laxative abuse (rare - diarrhoea is commoner) Idiopathic slow transit Idiopathic megarectum/colon |
- Most constipation does not need investigation, especially young, mildly affected patients.
- Indications for investigation include:
- Age >40yrs
- Recent change in bowel habit
- Associated symptoms (weight loss, rectal bleeding, mucus discharge, or tenesmus)
- Possible investigations include:
- Blood tests: FBC , U&E , Ca2+, TFTs.
- Sigmoidoscopy and biopsy of abnormal and normal mucosa.
- Barium enema if suspected colorectal malignancy.
- Special investigations (eg transit studies; anorectal physiology) are occasionally indicated.
- Treat the cause
- Mobilise the patient
- Consider drugs only if above measures fail
- Try to use drugs for short durations only
Drug therapy
| Drugs for constipation | |
|---|---|
Bulk producers:
|
Examples:
|
Stool softeners:
|
|
Stimulants:
|
|
Osmotic agents:
|
|
| Enemas and suppositories- useful additional treatment |
|
Cost
|
|
This is covered in the article on Constipation in Children.
Document references
- Constipation, Clinical Knowledge Summaries (January 2008)
Internet and further reading
- Jewell DJ, Young G; Interventions for treating constipation in pregnancy. Cochrane Database Syst Rev. 2001;(2):CD001142. [abstract]
- Palliative cancer care - constipation; Clinical Knowledge Summaries.
DocID: 2001
Document Version: 20
DocRef: bgp841
Last Updated: 18 Apr 2008
Review Date: 18 Apr 2010
Disclaimer: Patient UK has no control of the content of the above links. Inclusion does not imply endorsement by Patient UK.
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