Constipation

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Chapter 16 Constipation

INTRODUCTION

Description: Constipation is the infrequent passage of hard stools, often associated with mechanical or other means to stimulate bowel movements. It often also is related to changes in the size, consistency, and ease of bowel movement in the subjective definition of constipation.
Prevalence: Very common as a sporadic problem, 8% to 10% of women.
Predominant Age: Any, more common in youth and old age.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Inadequate dietary fiber and fluid intake, altered gastrointestinal motility (drugs, illness, injury, laxative abuse), metabolic (hypothyroidism, diabetes), mechanical (obstruction, impaction).
Risk Factors: Poor diet and fluid intake, inactivity, medications (narcotics, iron therapy), and sedentary lifestyle.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Bowel movements fewer than three times per week
• Hard stools
• Straining to have a bowel movement
• Inability to have bowel movements without medical or mechanical interventions (enemas, manual evacuation)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Hypothyroidism
• Rectocele
• Laxative abuse
• Dehydration
• Inappropriate expectation

Associated Conditions: Diverticulitis, abdominal pain.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: Radiography (abdominal plain film [kidneys, ureter, bladder], barium enema, defecography) may help to identify the source of the problem, but it is not required for diagnosis.
Special Tests: Rectal examination, flexible sigmoidoscopy, or colonoscopy should be considered for older patients.
Diagnostic Procedures: History and physical examination.

Pathologic Findings

None.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Fluids, dietary fiber, fiber supplements, and physical activity.
Specific Measures: Mechanical assistance (enemas), mechanical disimpaction.
Diet: Increased dietary fiber and adequate fluids, fiber supplements as needed.
Activity: No restriction, activity encouraged.
Patient Education: Reassurance, diet counseling.

Drug(s) of Choice

Fiber supplements, stool softeners (docusate sodium 100 mg PO two times daily), laxatives (use with caution).
Contraindications: Bowel obstruction, peritonitis.
Precautions: Laxative abuse and dependence are common. Patients should be warned about their appropriate use.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: Adequate fiber and fluid, physical activity.
Possible Complications: Impaction, fluid or electrolyte imbalance with laxative abuse, possible increase in the risk of colon cancer (proposed, but unproved).
Expected Outcome: Good with adequate diet, fluid, and activity.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although pregnancy (and associated iron supplementation) may make constipation worse.
ICD-9-CM Codes: 564.0, 306.4 (Psychogenic).

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REFERENCES

Level III

Bleser SD. Chronic constipation: let symptom type and severity direct treatment. J Fam Pract. 2006;55:587.

Frizelle F, Barclay M. Constipation in adults. Clin Evid. 2005;14:557.

Johnson DA. Treating chronic constipation: how should we interpret the recommendations? Clin Drug Investig. 2006;26:547.

Lacy BE, Weiser K. Gastrointestinal motility disorders: an update. Dig Dis. 2006;24:228.

Leung FW. Etiologic factors of chronic constipation: review of the scientific evidence. Dig Dis Sci. 2007;52:313. Epub 2007 Jan 12

Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology. 2006;130:1480.

Rapkin AJ, Mayer EA. Gastroenterologic causes of chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:663.

Thoua N, Emmanuel A. Treating functional lower gastrointestinal symptoms. Clin Med. 2006;6:449.

Wald A. Constipation in the primary care setting: current concepts and misconceptions. Am J Med. 2006;119:736.

Wald A. Chronic constipation: advances in management. Neurogastroenterol Motil. 2007;19:4.

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Chapter 16 Constipation

INTRODUCTION

Description: Constipation is the infrequent passage of hard stools, often associated with mechanical or other means to stimulate bowel movements. It often also is related to changes in the size, consistency, and ease of bowel movement in the subjective definition of constipation.
Prevalence: Very common as a sporadic problem, 8% to 10% of women.
Predominant Age: Any, more common in youth and old age.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Inadequate dietary fiber and fluid intake, altered gastrointestinal motility (drugs, illness, injury, laxative abuse), metabolic (hypothyroidism, diabetes), mechanical (obstruction, impaction).
Risk Factors: Poor diet and fluid intake, inactivity, medications (narcotics, iron therapy), and sedentary lifestyle.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Bowel movements fewer than three times per week
• Hard stools
• Straining to have a bowel movement
• Inability to have bowel movements without medical or mechanical interventions (enemas, manual evacuation)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Hypothyroidism
• Rectocele
• Laxative abuse
• Dehydration
• Inappropriate expectation

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