Constipation Disease

BASICS

DESCRIPTION

A combination of changes in the frequency, size, consistency, and ease of stool passage, which leads to an overall decrease in volume of bowel movements. Very subjective, each individual has their own threshold level.

System(s) affected: Gastrointestinal
Genetics: Unknown (the condition may be familial)
Incidence/Prevalence in USA:
- Higher at extremes of life, i.e., among infants/children and the elderly
- Common; affects a majority of persons during their lifetimes
Predominant age: All ages can be affected; more frequent at the extremes of life (infancy and old age)
Predominant sex: Female > Male

SIGNS AND SYMPTOMS

Less frequency of stooling than the patient perceives as "normal" (normal is 3-5 times/week)
Harder stool than "normal"
Smaller stools than normal (average < 35 grams/day is abnormal)
Impaction of stool secondary to hardness
Inspissated stool
Lack of consistent urgency to stool
Difficulty expelling feces from the rectum
Painful evacuation of feces
Lingering sense of incomplete emptying of the bowel
Abdominal fullness or a feeling of malaise secondary to inadequate bowel evacuation
Tenesmus

CAUSES

Electrolyte abnormalities
- Hypercalcemia
- Hypokalemia
Hormonal abnormalities
- Hypothyroidism
- Diabetes
Congenital impediments, e.g., aganglionic megacolon (Hirschsprung's disease) or excessively elongate, redundant, capacious bowel (dolichocolon)
Congenital or acquired neuromuscular bowel impairment ("pseudo-obstruction")
Concomitant illness, injury, or debility
Mechanical bowel impediment (obstruction or ileus, due to any cause)
Inadequate fluid intake
Side-effect of drugs (e.g., anticholinergic agents, opiates)
Chronic abuse of laxatives or cathartics
Psychiatric, cultural, emotional, environmental factors
Painful fecal evacuation from anal disease (e.g., fissures)

RISK FACTORS

Extremes of life (very young and very old)
Neurosis
Polypharmacy
Sedentary life style or condition

DIAGNOSIS

LABORATORY

Only necessary when other disorders are being considered
- CBC to detect anemia that may indicate colorectal neoplasm
- Thyroid functions
- Electrolytes, glucose, calcium

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

None in common, "functional" constipation
Paucity or absence of intramural enteric ganglia in certain cases of congenital or acquired megacolon
Neuromuscular abnormalities in certain cases of "pseudo-obstruction"

SPECIAL TESTS

In selected cases of long-standing constipation, timed measure of passage of ingested stool markers may help discern differing impediments
Anorectal motility in patients with suspected Hirschsprung's or anorectal motility disorders

IMAGING

Plain (KUB) film of the abdomen may help to discern the extent and nature of the problem
Barium enema or barium swallow with small bowel follow through looking for anatomical defects (mass lesions, ileus)
Cineradiography of passage of barium, instilled in, then expelled from the rectosigmoid segment ("defecography"), may help define evacuation disorders in selected cases

DIAGNOSTIC PROCEDURES

Digital rectal exam to rule out a rectal mass, check for blood in the stool, and define stool consistency
Sigmoidoscopy or colonoscopy is seldom required, unless needed to define an abnormality discovered by barium enema or when there is evidence of iron deficiency anemia or blood in the stool

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient usually, except when investigation discloses an underlying lesion or obstruction that requires hospitalization

GENERAL MEASURES

Attempt to eliminate medications that may cause or worsen constipation
Increase fluid intake
Modify diet
Enemas if other methods fail

SURGICAL MEASURES

N/A

ACTIVITY

Encourage exercise

DIET

If no anatomic abnormalities, increase fiber to approximately 15 gm/day (bran, fruit, green vegetables, and whole grain cereals and breads)
Encourage liberal intake of fluids

PATIENT EDUCATION

Define constipation and normal variations
Occasional mild constipation is normal
Instruction in consistent "bowel training" i.e., allowing adequate time for bowel evacuation in a quiet, unhurried environment; instruction in facilitating posture on commode, e.g., thighs flexed toward abdomen
Parents sometimes needs more treatment/advice than the constipated child

FOLLOW UP

PREVENTION/AVOIDANCE

Because for some patients a tendency to constipation is habitual, instruction in proper diet, bowel training, and use of bulk-forming supplements must be reinforced

POSSIBLE COMPLICATIONS

Acquired megacolon: in severe, long-standing cases
Cathartic colon: repeated laxative abuse
Fluid and electrolyte depletion: laxative abuse
Rectal ulceration ("stercoral ulcer") related to recurrent fecal impaction

EXPECTED COURSE AND PROGNOSIS

Constipation that is only occasional, brief, and responsive to simple measures is harmless. That which is habitual can be a lifelong nuisance.

MISCELLANEOUS

ASSOCIATED CONDITIONS

Debility, either general, as in the aged, or that imposed by specific, underlying illness

AGE-RELATED FACTORS

Pediatric: Consider Hirschsprung's disease
Geriatric:

Elderly persons, who have enjoyed regular bowel action throughout their lives, seldom suffer constipation due to age alone
Persons with a lifelong tendency to constipation often encounter increasing difficulty with advancing age
There is an increased incidence of colorectal neoplasms with age that may be associated with constipation.

Others: N/A

PREGNANCY

Women with a tendency to constipation may find the condition more troublesome in the third trimester and require dietary adjustment and supplements

OTHER NOTES

Obstipation refers to intractable constipation

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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