What is constipation defined as?
Change in a person’s normal bowel habit to infrequent or more difficult defaecation
What is it important to determine from the history when a patient presents with constipation?
- What the patient means by the term ‘constipation’
- What their normal bowel habit is
- How the presenting problem differs from ‘normal’
What are the main differential diagnoses of constipation?
- Change in diet
- Change in lifestyle or environment
- Immobility
- Drug-induced
- Anal fissure
- Haemorrhoids
- Poor fluid intake
- Hypothyroidism
- Rectal tumour
- Colonic carcinoma
What suggests that a change in diet is the cause of constipation?
History of reduced dietary fibre or reduced fliud intake
What confirms that a change in diet is the cause of constipation?
- Normal endoscopy
- Response to increased dietary fibre and increased fluid intake
What suggests that a change in lifestyle or environment is the cause of constipation?
History
What confirms that a change in lifestyle or environment is the cause of constipation?
- Normal sigmoidoscopy or colonoscopy
- Constipation resolves when return to previous lifestyle/environment
What suggests that immobility is the cause of constipation?
History
What confirms that immobility is the cause of constipation?
Normal sigmoidoscopy or colonoscopy
How is constipation caused by immobility managed?
- Increase mobilisation
- Increase dietary fibre
What suggests that constipation is drug-induced?
History of taking constipating drugs, e.g. opioids, hypotensive agents, aluminium alkalis etc, or history of purgative dependance
What confirms that constipation is drug-induced?
- Normal sigmoidoscopy or colonoscopy
- Resposne to withdrawal of suspected agent
What suggests that anal fissures are the cause of constipation?
- Skin tag
- Pain on defaecation
- Staining of toilet paper following defaecation
What confirms that anal fissures are the cause of constipation?
Physical examination of anal region
How are anal fissures managed?
- High-fibre diet
- Stool softners
- Warm sitz baths
- Analgesic cream
- Glyceryl trinitrate ointment
- Surgical intervention, e.g. sphincterectomy, if medical intervention fails
What suggests that haemorrhoids are the cause of constipation?
- Rectal bleeding following defaecation
- Perianal protrusion with pain
What confirms that haemorrhoids are the cause of constipation?
- Anal inspection
- Proctoscopy (haemorrhoids drop over the edge of proctoscope when it is withdrawn)
How are haemorrhoids managed?
- High-fibre diet
- Hydrocortisone suppositories to relieve irritation and pruritis
- Surgical intervention
What suggests that hypothyroidism is the cause of constipation?
- Cold intolerance
- Lethargy
- Weight gain
- Coarse and dry skin
- Puffy eyelids
