Diagnosis
Constipation
A condition characterized by difficult and infrequent bowel movements. Symptoms for ≥6 months and ≥2 of the following symptoms (Rome III criteria): [bie]
Straining
Hard stools
Sensation of incomplete evacuation
Sensation of anorectal obstruction/blockade
Manual maneuvers to facilitate defecations
<3 defecations/week
Etiology
Causes [bie][7qc]
Dietary Causes:
Inadequate fiber/fluid, overuse of caffeine/tea/alcohol/dairy products.
Motility/neurologic causes:
Stress, physical activity, opiate, anticholinergic, chronic laxative abuse, Hirschsprung disease, Chagas disease.
Anatomic causes:
Anal fissure, thrombosed hemorrhoids, cancer, volvulus, stricture, intussusception, rectocele, megacolon
Abnormal musculature:
Prune belly syndrome, gastroschisis, Down syndrome, and muscular dystrophy
Systemic disease:
Hypokalemia, hypercalcemia, hypomagnesemia, uremia, hyperparathyroidism, hypothyroidism, pregnancy, diabetes mellitus, Parkinson disease, Multiple Sclerosis, spinal cord lesion, head injury, cerebrovascular accident, depression, Chagas disease, dysautonomia, scleroderma, amyloidosis, mixed connective-tissue disease, amyloidosis, scleroderma, autonomic neuropathy, cognitive impairment, immobility, cardiac disease.
Drugs:
Antidepressants, heavy metal poisoning, anticholinergics, opioids, antacids, calcium channel blockers, NSAIDs, sympathomimetics, Dopamine agonists, antipsychotics, psychotropic drugs, cholestyramine, stimulant laxatives, antihistamines, anticonvulsants, antihypertensives (calcium channel blockers), diuretics, clonidine, antiarrhythmics, Beta-adrenoceptor antagonist, cholestyramine, antacids, sucralfate, Bismuth, iron supplements, lithium, vinca alkaloids, Vincristine, Cyclophosphamide, Barium sulfate, oral contraceptives, polystyrene resins, Pamidronate, alendronic acids, clozapine, haloperidol, risperidone, ephedrine, and terbutaline.
Pathophysiology
Multifactorial: gastrointestinal tract, nervous system, pelvic muscles
Reduced colonic motility --> delayed transit of stool
Impaired rectal sensation
Ineffective coordination of pelvic floor muscles during defecation
Complications [7qc]
Hemorrhoids
Anal fissures
Damage to the pelvic floor
Fecal incontinence
Urinary retention
Stercoral perforation
Rectal prolapse
Volvulus
Fistula-in-ano
Epidemiology
Prevalence per 100.000 [bie][a62][ucw][qrs][aca][6og][eib]
Symptoms & findings
Symptoms
Absent feces, Absent flatus, Diarrhea, Dyschezia, Hard stool, Hematochezia, Ileus, Nausea, Tenesmus, Vomiting
Clinical findings
Anamneses
None listed.
Localized findings
Approach
Blood test: complete blood cell count, electrolytes (hypokalemia/hypercalcemia), thyroid function tests (hypothyroidism)
Fecal occult blood testing (cancer)
Calprotectin
Blood gas
Anorectal examination
Abdominal x-ray
Colonic transit
Barium enema
Gastroscopy
Colonoscopy
Colonic manometry --> few high-amplitude contractions --> defecatory disorder
Defecography
CT abdomen
Treatment
Laxatives: [ks4][bie]
Bulking agents
Osmotic laxatives
Stool softeners
Stimulant laxatives
Fluid intake is evidence of dehydration
Defecatory disorders --> biofeedback-aided pelvic floor retraining
Surgery:
Subtotal Colectomy
Antegrade colonic enema: infuse water through an appendiceal conduit --> colonic emptying
Sacral Nerve Stimulation
Surgery for Pelvic Floor Dysfunction
Transanal resection (rectal intussusception and rectoceles)
Differential diagnoses
Achalasia, Amyloidosis, Anal fissure, Anorectal fistula, Anorectal malformation, Anxiety, Appendicitis, Ascites, Autonomic neuropathy, Bacterial overgrowth syndrome, Celiac disease, Chagas disease, Colorectal cancer, Crohn disease, Depression, Diabetes mellitus, Diverticulitis, Drug side effects, Eosinophilic gastroenteritis, Fecal impaction, Fecalith, Femoral hernia, Gallstone Ileus, Gastrointestinal obstruction, Giardiasis, Hemorrhoids, Hirschsprung's Disease, hookworm disease, Hyperparathyroidism, Hypopituitarism, Hypothyroidism, Incisional hernia, Inguinal hernia, Intestinal hypoperistalsis syndrome, Irritable bowel syndrome, Lactose intolerance, Lead toxicity, Multiple sclerosis, Necrotizing enterocolitis, Ogilvie syndrome, Parkinson's disease, Peritonitis, Postoperative paralytic ileus, Pregnancy, Rectal prolapse, Rectocele, Renal failure, Scleroderma, Sepsis, Spinal cord injury, Systemic lupus erythematosus, Toxic megacolon, Ulcerative colitis, Umbillical hernia
References
[1] Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013 Jan;144(1):218-38.
[2] Diaz S, Bittar K, Hashmi MF, et al. Constipation. [Updated 2023 Nov 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513291/
[3] Hammond EC. Some Preliminary Findings on Physical Complaints from a Prospective Study of 1,064,004 Men and Women. Am J Public Health Nations Health. 1964 Jan;54(1):11-23.
[4] Sandler RS, Jordan MC, Shelton BJ. Demographic and dietary determinants of constipation in the US population. Am J Public Health. 1990 Feb;80(2):185-9.
[5] Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr;99(4):750-9.
[6] https://emedicine.medscape.com/article/928185
[7] Talley NJ, O'Keefe EA, Zinsmeister AR, Melton LJ 3rd. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology. 1992 Mar;102(3):895-901.
[8] https://www.sialliance.health.nz/wp-content/uploads/2016-SIAPO-Constipation.pdf
[9] Vazquez Roque, M., & Bouras, E. P. (2015). Epidemiology and management of chronic constipation in elderly patients. Clinical Interventions in Aging, 10, 919–930.
[10] http://emedicine.medscape.com/article/184704 (2014-01-02); [Medscape]