Constipation

Question 1

What is constipation defined as?

Answer 1

Change in a person’s normal bowel habit to infrequent or more difficult defaecation

Question 2

What is it important to determine from the history when a patient presents with constipation?

Answer 2

• What the patient means by the term ‘constipation’
• What their normal bowel habit is
• How the presenting problem differs from ‘normal’

Question 3

What are the main differential diagnoses of constipation?

Answer 3

• Change in diet
• Change in lifestyle or environment
• Immobility
• Drug-induced
• Anal fissure
• Haemorrhoids
• Poor fluid intake
• Hypothyroidism
• Rectal tumour
• Colonic carcinoma

Question 4

What suggests that a change in diet is the cause of constipation?

Answer 4

History of reduced dietary fibre or reduced fliud intake

Question 5

What confirms that a change in diet is the cause of constipation?

Answer 5

• Normal endoscopy
• ​Response to increased dietary fibre and increased fluid intake

Question 6

What suggests that a change in lifestyle or environment is the cause of constipation?

Answer 6

History

Question 7

What confirms that a change in lifestyle or environment is the cause of constipation?

Answer 7

• Normal sigmoidoscopy or colonoscopy
• Constipation resolves when return to previous lifestyle/environment

Question 8

What suggests that immobility is the cause of constipation?

Answer 8

History

Question 9

What confirms that immobility is the cause of constipation?

Answer 9

Normal sigmoidoscopy or colonoscopy

Question 10

How is constipation caused by immobility managed?

Answer 10

• Increase mobilisation
• Increase dietary fibre

Question 11

What suggests that constipation is drug-induced?

Answer 11

History of taking constipating drugs, e.g. opioids, hypotensive agents, aluminium alkalis etc, or history of purgative dependance

Question 12

What confirms that constipation is drug-induced?

Answer 12

• Normal sigmoidoscopy or colonoscopy
• Resposne to withdrawal of suspected agent

Question 13

What suggests that anal fissures are the cause of constipation?

Answer 13

• Skin tag
• Pain on defaecation
• Staining of toilet paper following defaecation

Question 14

What confirms that anal fissures are the cause of constipation?

Answer 14

Physical examination of anal region

Question 15

How are anal fissures managed?

Answer 15

• High-fibre diet
• Stool softners
• Warm sitz baths
• Analgesic cream
• Glyceryl trinitrate ointment
• Surgical intervention, e.g. sphincterectomy, if medical intervention fails

Question 16

What suggests that haemorrhoids are the cause of constipation?

Answer 16

• Rectal bleeding following defaecation
• Perianal protrusion with pain

Question 17

What confirms that haemorrhoids are the cause of constipation?

Answer 17

• Anal inspection
• Proctoscopy (haemorrhoids drop over the edge of proctoscope when it is withdrawn)

Question 18

How are haemorrhoids managed?

Answer 18

• High-fibre diet
• Hydrocortisone suppositories to relieve irritation and pruritis
• Surgical intervention

Question 19

What suggests that hypothyroidism is the cause of constipation?

Answer 19

• Cold intolerance
• Lethargy
• Weight gain
• Coarse and dry skin
• Puffy eyelids