Constipation

Alarm Symptoms? Fever, weight loss, melena , hematochezia, nausea, vomiting, abdo pain, saddle anesthesia

Yes: Urgent evaluation for cancer, bowel obstruction , spinal cord process

Metabolic, endocrinologic, neurologic, muscular, connective tissue or psychiatric disease associated with constipation

Yes: Consider constipation caused by associated condition

New medications?

Yes

Medication induced constipation

Acute

Chronic

Consider recent bed rest, change in diet, psychosocial stressor as possible cause of constipation

Difficulty passing even soft stools or enema fluid, need to press around pelvic floor to defecate, need to digitally evacuate, feeling of blockage, difficulty relaxing muscles to move bowels

Pain relieved by bowel movement, passing mucus, sense of incomplete evacuation, symptoms increased by stress, bloating

Fewer than 2 bowel movements per week, laxative dependent, constipation since childhood

Defacatory disorder

Normal transit constipation (IBS)

Slow transit constipation

DDx

Metabolic and endocrine conditions

Neurogenic disorders

Medication side-effect (Recent)

Muscular and connective tissue disorder

Anorectal obstruction

Colon or rectal cancer

Colonic polyps

Anal Fissure

Fecal Impaction

Ileus

Megarectum (a feces filled rectum with nerve or muscle abnormalities that prevent function of the external anal sphincter and puborectalis muscle ; most commonly in the elderly)

Defecatory disroders

Thrombosed hemorrhoids

Strictures

Pregnancy

Hypomagnesemia

Hypothyroidism

Hypokalemia

Lead poisoning

Hyperparathyroidism

Preganncy

Hypercalcemia

Uremia

Diabetes mellitus

Hirschsrung disease

Neurofibromatosis

Chagas disease

CNS disorders

Autonomic neuropathy

Multiple sclerosis

Spinal cord tumor or injury

Parkinsonism

Cerebrovascular accident

Amyloidosis

Systemic sclerosis

Myotonic dystrophy

Antipsychotics

Antispasmodics

Antidepressants

Calcium supplments

Antidiarrheals

Cholestyramine

Anticholinergics

Antacids(aluminium and calcium containing)

Clonidine

Iron supplements

Levodopa

Opiods

Sympathomimetics

NSAIDS

Verapamil

Colorectal motility dysfunction

Slow transit constipation

Constipation predominant IBS

Defecatory Disorders

Idiopathic chronic constipation

Psychosocial

Depression

Low-fibre diet

Sedentary lifestyle

Somatization

Approach

1) Whether really got constipation? Ask normal and now what is the bowel frequency? When did it start? Post op: Ileus, adhesions. Recent: Colon cancer, fecal impaction, medication side effect. Longstanding: IBS, chronic idiopathic constipation. Lifelong: Hirschsrung disease

2) Acute or chronic (> 3months)

Chronic: Functional rather than serious disease usually

3) Assess for Alarm symptoms

4) Assess for symptoms of medical conditions

Significant abdo pain: Cancer, diverticulitis for serious causes. Benign: IBS, Medication, hemorrhoids

Hematochezia, melena: (Serious conditions tend to have bld mix in stool) Colon cancer, diverticulitis, stricture, anal fissure/ulcer(bld on outside of stools) for serious. Benign: Hemorrhoids(bld on outside of stools plus drops of blood in toilet water)

Serious diagnosis:Colon cancer, strictures,Spinal cord tumor/trauma, bowel obstruction or ileus

Recent onset: Colon cancer, Metabolic or endocrine disorder for serious. Benign: Medication, psychosocial stressor, immobility

Acute onset constipation with fever, abdo pain, weight loss, rectal bleeding suggest serious organic illness like colon cancer, stricture as does a family history of inflammatory bowel disease or cancer. Constipation over age 50 --> Increased incidence of diverticulitis, colon cancer, hypothyroidism and Parkinson's disease

Unintentional weight loss:Colon cancer, depression

5) Drugs? Fam History of colorectal cancer? Worse constipation with stress --> IBS (Abdo pain/Discomfort 3 or more days per month in the past 3 months that is improved with bowel movement. Discomfort associated with change in consistency of stools/Number of bowel movement? If 2 or more over 6 months --> IBS)

6) Diet

7) Use Bristol Stool scale to estimate transit time(pic)

Chronic: At least 3 months in the preceding 6 months, need not be consecutive or 2 of the following: Straining during at least 1/4 of defecations, Lumpy or hard stools during at least 1/4 defecations, sensation of incomplete evacuation in at least 1/4 defecations, sensation of anorectal obstruction/blockage in at least 1/4 of defecations, fewer than 3 defecations per week, manual removal(digital evacuation)

Change in stool caliber (Have you noticed your stools gotten narrow like a pencil or flattened like a ribbon): Serious --> Colon cancer, stricture, anal fissure. Benign: IBS

Nausea, vomiting: Bowel obs(tumor or stricture eg) Benign: IBS

Fever:Diverticulitis, Cancer

Back pain, saddle anesthesia, leg weakness, numbness, difficulty urinating?: Spinal cord process (eg cauda equina)

Acute: Ask

Nausea/Vomiting?:Intestinal Obstruction

Fecal incontinence?: Fecal impaction

New medication: Medication side effect

Abdo pain/Cramps: Intestinal obstruction(eg cancer, diverticulitis, IBS,ileus)

Able to pass gas?: No suspect Complete intestinal obstruction

Tell me what you have eaten in the past 24 hr working backwards from when you first entered here?

What were your bowel habits like prior to this episode?

Decrease in fibre and liquid and lead to constipation

Has your level of activity changed recently? Sedentary lifestyle or bed rest can lead to constipation

Bouts of constipation alternating with diarrhea: Colon cancer, IBS, diabetic neuropathy, fecal impaction

If abnormal--> Chronic condition progressing to complete obstruction

Have you had abdominal surgery or radiation? : Strictures, adhesions

Have you suffered a back injury?:Spinal cord trauma

Do you have new weakness in your legs?Saddle anesthesia? Difficulty passing urine?: Spinal cord damage from tumor or trauma

Chronic ask:

Fam His

Worse constipation with stress --> IBS (Abdo pain/Discomfort 3 or more days per month in the past 3 months that is improved with bowel movement. Discomfort associated with change in consistency of stools/Number of bowel movement? If 2 or more over 6 months --> IBS). Pass mucus. Long standing.

Post op

Recent

Longstanding

How often bowel movement? What is normal?: Less than 2 per week --> Slow transit constipation

Stools thin like pencil:Narrowing of the distal colon, sigmoid or rectum from colon cancer or stricture

Pass mucus: IBS

Watery: In debiliatted or elderly person, consider fecal impaction (liquid stool passing around the obstructing fecal mass)

Constipation alternating with diarrhea? IBS or Colorectal cancer

Mixed with blood: Colon cancer

Outside of stools streak with blood? Hemorrhoids, fissures, ulcers

Black stools:Bismuth subsalicylate, iron supplements, upper GI bleeding

Increase urinary frequency/thirst: Diabetic autonomic neuropathy

Weight gain, decrease energy levels, swelling in legs: Hypothyroidism

How is your sleep? Appetite? Interest in things? Mood? Concentration?: Depression --> constipation

Level of activity: Decrease --> Constipation

Pregnancies? Multiparity is associated with defecatory disorder

Diet pass 24 hrs: Low fibre, low liquid

Increase fiber improve means normal transit constipation

If take laxative, have you had a bowel movement without laxative? If no suggest slow transit constipation. If use laxative abuse can lead to constipation. After purging with laxative, might need a few days to have normal bowel movement.

Medication side effect

When you feel like emptying your bowels? Do you heed it? Failure to heed it chronically may lead to chronic rectal distention, lax muscle tone, slow transit time, and chronic constipation

Do you have the feeling of incomplete evacuation: IBS

Abdo pain /bloating associated with bowel movement: IBS or intestinal obstruction

If relieved by it : IBS

If acute: Intestinal obstruction(Strictures, colon cancer, fecal impaction etc)