Constipation

Question 1

What must you elucidate when a patient say they are constipated?

Answer 1

Frequency
Ease of passage
Volume

Question 2

What are the differential diagnoses in a patient with constipation due to abnormal bowel peristalsis?

Answer 2

IBS
Medications

Hypothyroidism
Hypercalcaemia
Hypokalaemia
Spinal cord compression
MS
Parkinson's disease
Diabetic neuropathy
Idiopathic megacolon/slow transit

Question 3

What are the differential diagnoses for hard faeces?

Answer 3

Lack of dietary fibre

Dehydration

Question 4

What are the differential diagnoses of bowel obstruction?

Answer 4

Colorectal adenocarcinoma
Sigmoid volvulus

Other pelvic masses
Colonic strictures

Question 5

What are the differential diagnoses of a patient not pushing?

Answer 5

Haemorrhoids
Anal fissure
Pelvic floor dysfunction (eg after hysterectomy)

Question 6

What are the red flags in a patient with constipation?

Answer 6

Severe, persistent constipation that is unresponsive to treatment

Rectal bleeding, tenesmus, or intermittent mucoid diarrhoea

Significant weight loss, iron-deficiency anaemia, and/or night sweats

PMH of UC or polyps

Strong family history of colon caner or colonic polyps

Question 7

What does intermittent diarrhoea and constipation suggest?

Answer 7

IBS

Question 8

What does tenesmus suggest?

Answer 8

Persistent mass in the rectum

Question 9

Why would you ask about polyuria or thirst in a patient with constipation?

Answer 9

These would suggest hypercalcaemia

Question 10

What is the faecal occult blood test (FOBT) used for?

Answer 10

Screening for colon cancer

May also be due to colonic angiodysplasia, colonic polyps, haemorrhoids, aspirin or warfarin

Warrants further investigation

Question 11

What are Carcinoembryonic antigen (CEA)/CA19-9/CA125?

Answer 11

Markers of colon cancer

But they lack specificity

Question 12

What is the constellation of symptoms in hypercalcaemia?

Answer 12

Moans (depression), groans (aches and pain), bones, and stones (renal stones)

Question 13

What can the underlying causes of the hypercalcaemia be?

What would the blood tests results be for each of these?

Answer 13

Bone metastases
- High ALP, low PTH and high phosphate

Myeloma
- Normal ALP, low PTH and high phosphate

Hyperparathyroidism
- Normal/high ALP, normal/high PTH and low phosphate

Vit D overdose
- Low ALP, low PTH and high phosphate