Constipation

Question 1

Constipation is a common problem. It means either going to the toilet less often than usual to empty the bowels, or passing hard or painful stools (faeces). How many of the following are required to be diagnosed with constipation in a child according to NICE?

• <3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale (BSS))
• hard or large stools
• rabbit stool (scale 1 on BSS)

1 - 1 or more
2 - 2 or more
3 - all 3

Answer 1

2 - 2 or more

Question 2

How common is constipation in the general population?

1 - 1-2%
2 - 5-10%
3 - 30-40%
4 - >75%

Answer 2

1 - 1-2%

Question 3

Constipation in the general population has an incidence of 1-2%, but what is the incidence in children?

1 - 1-2%
2 - 5-30%
3 - 30-40%
4 - >75%

Answer 3

2 - 5-30%

Question 4

Is constipation more common in men or women?

Answer 4

• 2-3 times more common in women

Question 5

How long does constipation have to be present for to be diagnosed as chronic constipation?

1 - >2 weeks
2 - >8 weeks
3 - >16 weeks
4 - >32 weeks

Answer 5

2 - >8 weeks

Question 6

Is constipation more common in younger or older ages?

Answer 6

• incidence increases with age

Question 7

What is the normal stool frequency in the 1st week of life?

1 - 8/day
2 - 4/day
3 - 2/day
4 - 1/day

Answer 7

2 - 4/day

After the 1st week, it is typically 1/day

Question 8

Which 2 of the following are the most common functional/idiopathic (no physical cause) causes of acute constipation?

1 - dehydration
2 - behavioural (nervous at school etc)
3 - hirschsprung’s disease
4 - hypercalcaemia
5 - hypothyroidism

Answer 8

1 - dehydration
2 - behavioural (nervous at school etc)

Question 9

Which 2 of the following medications are more commonly associated with acute constipation?

1 - NSAIDs
2 - opioids (morphine, codeine)
3 - loperamide (imodium)
4 - anti-depressants

Answer 9

2 - opioids (morphine, codeine)
3 - loperamide (imodium)

Question 10

Acute presentations of constipation can begin as an acute pathophysiology, but can also be the begining of a chronic pathology. What is the most common thing that constipation is compared against?

1 - malignancy
2 - bowel obstruction
3 - neurological disorders
4 - idiopathic

Answer 10

2 - bowel obstruction

Question 11

Opiod medication bind to receptors in the brain and GIT. What type of membrane receptors are these?

1 - ion channel receptors
2 - enzyme associated receptors
3 - passive diffusion
4 - G couple protein receptors

Answer 11

4 - G couple protein receptors

Question 12

Endorphones are endogenous opioid neuropeptides and peptide hormones. When they are released they bind to the inhibitory neurons, namely mu, kappa, and delta which allow dopamine, serotonin, and norepinephrine to be released into the CNS. What does the release of dopamine, serotonin, and norepinephrine cause a reduction in?

1 - muscle contractions
2 - pain
3 - abdominal peristalsis
4 - bladder control

Answer 12

2 - pain

Question 13

The GIT walls contain mu opiod receptors. What are the 2 major effects activation of the mu opiod receptors in the GIT can have?

1 - reduced GIT motility
2 - increased GIT motility
3 - increased sphincter tone
4 - increased fluid secretion in bowels

Answer 13

1 - reduced GIT motility
3 - increased sphincter tone

Both cause constipation

Question 14

The GIT walls contain mu opioid receptors. Opioid is able to bind with all opioid receptors inducing reduced GIT motility and increased sphincter tone. What medication, as part of our core drug list is used to treat diarrhoea, but as a consequence can cause constipation?

1 - loperamide (imodium)
2 - NSAIDs
3 - macrogol
4 - Ondansetron

Answer 14

1 - loperamide (imodium)
- specifically in the large intestines

Question 15

When we ask about abdominal pain, we need to ask ourselves, is this a functional or organic cause. Which of the following is NOT a functional cause of abdominal pain?

1 - IBS
2 - abdominal migraine
3 - constipation
4 - functional dyspepsia

Answer 15

3 - constipation

Functional = pain is not physical in nature

Organic = pain has a specific physical cause

Question 16

When we ask about abdominal pain, we need to ask ourselves, is this a functional or organic cause. Which of the following is NOT an organic cause of abdominal pain?

1 - IBS
2 - peptic ulcers
3 - constipation
4 - IBD
5 - pancreatitis

Answer 16

1 - IBS

Question 17

What is the most common cause of chronic constipation?

1 - IBD
2 - coeliac disease
3 - irritable bowel syndrome
4 - reflux

Answer 17

3- irritable bowel syndrome

Question 18

Can a UTI be an sign of constipation?

Answer 18

• yes

Constipation can lead to bladder/urethral obstruction

Question 19

Pregnancy is a common cause of constipation. What % of women experience constipation?

1 - 4%
2 - 15%
3 - 40%
4 - 90%

Answer 19

3 - 40%

Question 20

Is hypo or hyperthyroidism linked with constipation?

Answer 20

• hyperthyroidism = increased metabolic rate and muscle contractions including GIT smooth muscle, causing diarrhoea
• hypothyroidism = reduced metabolic rate and muscle contractions including GIT smooth muscle, causing constipation

Question 21

Chronic constipation can cause anorectal problems,. Which of the following is NOT one of these?

1 - haemorrhoids
2 - anal fissures (tears of rectum)
3 - painful defaecation
4 - rectal prolapse (bottom end of rectum falls out)
5 - rectal obstruction

Answer 21

5 - rectal obstruction

Question 22

Which congenital condition causing an absence of ganglia in the bowel resulting in a lack of peristalsis can cause constipation and is often diagnosed in infancy?
- 90% diagnosed in infancy
- 1% diagnosed in adults

1 - Coeliac disease
2 - Hirschsprung’s disease
3 - Coeliac disease
4 - Rotavirus disease

Answer 22

2 - Hirschsprung’s disease
- THIS IS A RED FLAG!!!

Can often be difficult to meconium, which can be very dangerous, but means patients can be diagnosed very early

Patients can also have abdominal distension with vomiting as food comes back up the wrong way

Question 23

Hirschsprung’s disease is a congenital condition causing an absence of ganglia in the bowel resulting in a lack of peristalsis can cause constipation and is often diagnosed in infancy. What investigation is required to aid with the diagnosis of Hirschsprung’s disease?

1 - X-ray
2 - CT scan
3 - digital rectal exam
4 - rectal biopsy

Answer 23

4 - rectal biopsy

Question 24

All of the following can cause constipation. Which 2 of the following are most common?

1 - Coeliac disease
2 - Hirschsprung’s disease
3 - IBD disease
4 - Hypothyroidism

Answer 24

1 - Coeliac disease
4 - Hypothyroidism

Question 25

If a child presents with constipation in the 1st week of life, is this more likely to be idiopathic or non-idiopathic?

Answer 25

- non-idiopathic Likely to be congenital, like Hirschsprung’s disease

Question 26

If a child failed top pass meconium, is this more likely to be idiopathic or non-idiopathic?

Answer 26

- non-idiopathic An idiopathic cause of constipation would typically pass in the 1st 2 weeks Idiopathic causes of failure to pass meconium is a RED FLAGS

Question 27

If a child has poor growth and general well being this is an amber flag. Is this more likely to be idiopathic or non-idiopathic?

Answer 27

- non-idiopathic

Question 28

Which of the following is the least likely symptom to present with in a child with constipation? 1 - Hard stools 2 - Straining or pain and bleeding 3 - Abdominal pain 4 - Increased appetite 5 - Faecal impaction-severe symptoms, overflow soiling and a faecal mass on abdominal examination.

Answer 28

4 - Increased appetite Typically reduced appetite as eating can worsen symptoms Eating does improve with passage of stool.

Question 29

All of the following can occur in chronic constipation, which 2 are the most common symptom? 1 - abdominal pain 2 - bloating 3 - overactive bladder 4 - urine urgency

Answer 29

1 - abdominal pain 2 - bloating

Question 30

Patients with chronic constipation can have faecal impactio, what is this faecal impaction? 1 - stool becomes very thin to pass stool causing diarrhoea 2 - stool causing bowel infection 3 - stool becomes so hard it cannot be passed 4 - all of the above

Answer 30

3 - stool becomes so hard it cannot be passed Can also lead to overflow diarrhoea as solid cannot move, but fluid around it does

Question 31

In patients with chronic constipation, all of the following should be performed, but which is least important initially? 1 - FBC 2 - ESR and CRP 3 - TFTs 4 - LFTs

Answer 31

4 - LFTs - hypothyroidism can cause constipation

Question 32

In patients with chronic constipation, which 2 of the following stool tests that should be performed? 1 - inflammatory marker faecal calprotectin 2 - amylase 3 - qFIT for blood caused by cancer 4 - bile acids

Answer 32

1 - inflammatory marker faecal calprotectin 3 - qFIT for blood caused by cancer

Question 33

In an acute setting with someone with constipation, which imaging techniques is best to rule out a bowel obstruction? 1 - MRI 2 - ultrasound 3 - CT scan 4 - X-ray

Answer 33

3 - CT scan X-ray can also be used

Question 34

In someone with constipation, what invasive techniques could be used to identify the cause? 1 - blood samples 2 - colonoscopy 3 - CT scan 4 - rectal biopsy

Answer 34

2 - colonoscopy - virtual colonoscopy is also possible Bowel transit time tests and pelvic floor tests can also be performed.

Question 35

Which 2 of the following are important to help manage constipation? 1 - balanced diet, fluid intake and increased fibre intake 2 - ensure children are potty trained by 2 years old 3 - allow nappies to be worn for as long as possible to reduce anxiety 4 - support good toileting habits

Answer 35

1 - balanced diet, fluid intake and increased fibre intake 4 - support good toileting habits

Question 36

Which of the following is the most common laxative used in the treatment of constipation? 1 - Ispaghula husk 2 - Senna 3 - Docusate sodium 4 - Macrogol

Answer 36

4 - Macrogol This is polyethylene glycol, but the brand name is macrogel, also known as Laxido, CosmoCol, Molaxole and Molative

Question 37

What class of laxatives does Macrogol, the most commonly used laxative come under? 1 - osmotic 2 - bilk forming 3 - stimulant 4 - stool softener

Answer 37

1 - osmotic These are not well absorbed so fluid is pumped into the bowel in an osmotic gradient Often used in combination with stimulant laxatives such as Senna or glycerol suppositories which irritate the GIT walls, drawing in electrolytes from the enterocytes, which subsequently draws water into the lumen

Question 38

Should children be started on a set dose based on weight, or always started on the lowest doses?

Answer 38

- always put on lowest dose Children remain on the laxatives until they have 1-2 soft stools formed

Question 39

What is the definition of chronic diarrhoea? 1 - >24 weeks 2 - >12 weeks 3 - >6 weeks 4 - >2 weeks

Answer 39

2 - >12 weeks