Constipation

Question 1

What is constipation?

Answer 1

Infrequent passage of stool, generally defined as ≤3 bowel movements per week
- Absolute Constipation ⇒ no faeces or flatus

Question 2

What are the 2 types of constipation you can have?

Answer 2

1. Primary Constipation → most commonly due to poor diet (lack of fibre) or dehydration and insufficient exercise
2. Secondary Constipation → colorectal cancer, diverticulosis, haemorrhoids, bowel obstruction, diverticulitis, IBS, hypothyroidism, drug induced (opiods) etc.

Question 3

What are the risk factors for constipation?

Answer 3

female, age >65, low fibre intake, sedentary lifestyle, medicines that induce constipation (opiates, CCBs, antipsychotics)

Question 4

What are the presenting symptoms of constipation?

Answer 4

1. Infrequent Stools → <3 defecations/wk
2. Difficult Defecation
3. Excessive Straining
4. Sensation of Incomplete Evacuation (Tenesmus)
5. Hard Stools
6. May cause confusion if impactation.
7. Can cause outflow obstruction and trigger episodes of urinary retention in patients with enlarged prostates

Question 5

What medical aid is designed to classify stools?

Answer 5

“Bristol Stool Chart”
Constipation is typically type 1 or 2
- Type 1 - hard lumps, like nuts
- Type 2 - sausage-shaped, but lumpy
- Type 3 - sausage-shaped, with cracks on the surface
- Type 4 - like a smooth sausage or snake
- Type 5 - soft blobs with clear cut edges
- Type 6 - fluffy pieces with ragged edges, mushy
- Type 7 - watery, no solid pieces

Question 6

What investigations are used to diagnose/ monitor constipation?

Answer 6

1. Anal Manometry → indicated for evaluation of constipation or functional anorectal pain
2. FBC → if indication of secondary cause, especially iron deficiency anaemia
3. TFTs → hypothyroidism
4. AXR → rectal masses or faecal impactation

Question 7

What red flags may be associated with constipation that would promt further investigation?

Answer 7

• Change in bowel habit for more than 6 weeks.
• Persistent rectal bleeding.
• Weight loss, night sweats, appetite loss.
• Family history of colorectal pathology.
• Pain.
• Vomiting.
• Abdominal bloating.
• New-onset confusion.

Question 8

How is constipation managed?

Answer 8

1. Lifestyle Changes → high fibre diet, increased fluid intake, exercise
2. Bulk Laxatives + Stool Softeners → preferred pharmalogical therapy
3. Osmotic Laxative → lactulose
4. Stimulant Laxative (if osmotic doesn’t work) → senna
5. Prunes = natural alternative to laxatives