Constipation bmj, nice and cks

Question 1

Constipation Overview

Answer 1

Constipation is a heterogeneous, symptom-based disorder. Patients describe defecation that is problematic because of infrequent and/or hard stools, difficulty passing stools (often involving straining), or the sensation of incomplete emptying or anorectal blockage.

Question 2

Rome IV Criteria

Answer 2

Spontaneous bowel movements occurring fewer than three times a week, with stools often being dry, hard, or lumpy and may be abnormally large or small. In practice constipation is often defined as passage of stools less frequently than the person’s normal pattern.

Question 3

Chronic Constipation Definition,

Answer 3

Symptoms present for at least three months

Question 4

Overflow Faecal Incontinence

Answer 4

Overflow faecal incontinence (previously known as ‘encopresis’ or ‘bypass soiling’) is leakage of liquid stool from the proximal colon around impacted faeces, where small quantities of stool may be passed frequently and without sensation.

Question 5

Functional Constipation

Answer 5

• Functional (primary or idiopathic) constipation is chronic constipation without a known cause. Using symptom-based criteria an international panel of experts classified this group into:
  o Dyssynergistic defecation: paradoxical contraction or inadequate relaxation of pelvic floor muscles during defecation.
  o Slow transit — prolonged delay in passage of stool through the colon and/or poor propulsion during defecation.
  o Irritable bowel syndrome-constipation (IBS-C).

Question 6

Secondary Constipation

Answer 6

• Secondary (organic) constipation is constipation caused by medication or an underlying medical condition, including endocrine, metabolic, neurological or primary diseases of the colon, for example stricture, malignancy, or proctitis.

Question 7

Risk Factors for Constipation

Answer 7

Risk factors for developing constipation include:
* Social
o Low fibre diet or low calorie intake.
o Difficult access to toilet, or changes in normal routine or lifestyle.
o Lack of exercise or reduced mobility.
o Limited privacy when using the toilet.
o Low educational levels or socio-economic deprivation.
o A family history of constipation.
* Psychological
o Anxiety and/or depression.
o Somatization disorders.
o Eating disorders.
o History of sexual abuse.
* Physical
o Female sex.
o Older age.
o Pyrexia, poor fluid intake/dehydration, immobility.
o Sitting position on a toilet seat (compared with the squatting position for defecation).

Question 8

Medications Causing Constipation

Answer 8

Possible secondary causes of constipation include:
* Medications
o Aluminium-containing antacids; iron or calcium supplements.
o Analgesics, such as opiates (up to 80% of patients, even with concomitant use of laxatives) and nonsteroidal anti-inflammatory drugs (NSAIDs).
o Antimuscarinics, such as procyclidine and oxybutynin.
o Antidepressants, such as tricyclic antidepressants.
o Antipsychotics, such as amisulpride, clozapine, or quetiapine.
o Antiepileptic drugs, such as carbamazepine, gabapentin, oxcarbazepine, pregabalin, or phenytoin.
o Antihistamines, such as hydroxyzine.
o Antispasmodics, such as dicycloverine or hyoscine.
o Calcium-channel blockers, such as verapamil.
o Diuretics, such as furosemide.
* Organic causes
o Endocrine and metabolic diseases:
 Diabetes mellitus (with autonomic neuropathy). See the CKS topics on Diabetes - type 1 and Diabetes - type 2 for more information.
 Hypercalcaemia and hyperparathyroidism. See the CKS topic on Hypercalcaemia for more information.
 Hypermagnesaemia.
 Hypokalaemia.
 Hypothyroidism. See the CKS topic on Hypothyroidism for more information.
 Uraemia.
o Myopathic conditions:
 Amyloidosis.
 Myotonic dystrophy.
 Scleroderma.
o Neurological conditions:
 Autonomic neuropathy.
 Cerebrovascular disease. See the CKS topic on Stroke and TIA for more information.
 Hirschsprung’s disease. See the CKS topic on Constipation in children for more information.
 Multiple sclerosis. See the CKS topic on Multiple sclerosis for more information.
 Parkinson’s disease. See the CKS topic on Parkinson’s disease for more information.
 Spinal cord injury, tumours.
o Structural abnormalities:
 Anal fissures, strictures, haemorrhoids. See the CKS topics on Anal fissure and Haemorrhoids for more information.
 Colonic strictures (for example following diverticulitis, ischaemia, or surgery). See the CKS topic on Diverticular disease for more information.
 Inflammatory bowel disease. See the CKS topics on Crohn’s disease and Ulcerative colitis for more information.
 Obstructive colonic mass lesions (for example due to colorectal cancer). See the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for more information.
 Rectal prolapse or rectocele.
 Postnatal damage to pelvic floor or third degree tear.
o Other:
 Irritable bowel syndrome. See the CKS topic on Irritable bowel syndrome for more information.
 Slow transit constipation.
 Pelvic or anal dyssynergia.
Includes aluminium-containing antacids, iron supplements, opiates, NSAIDs, antimuscarinics, antidepressants, antipsychotics, antiepileptics, antihistamines, antispasmodics, calcium-channel blockers, and diuretics

Question 9

Management of Constipation,

Answer 9

Involves dietary and lifestyle changes, use of laxatives, possible use of enemas or manual removal, and addressing any underlying conditions

Question 10

Prognosis of Chronic Constipation

Answer 10

• The prognosis of chronic constipation is variable and will depend on the underlying cause.
• Patients often require weeks or years of lifestyle changes and laxative treatment.
  o A 2017 prospective cohort study (n = 878 patients attending clinic) found 48.5% of people had chronic constipation for more than 10 years [Bellini, 2017].
  o In the same study patients with IBS-C reported more severe symptoms than other constipation types.
• Constipation is not life-threatening but does affect quality of life.
• Faecal impaction may require emergency admission. There is an associated social and economic burden; in England between April 2013 and 2014 there were 63,427 patients admitted with constipation and this accounted for 159,997 bed days [Emmanuel, 2017].

Question 11

History-Taking

Answer 11

History-Taking
* Stool Patterns: Check if the child has fewer than three complete stools per week, observes hard large stools, or “rabbit droppings” type stools.
* Symptoms Associated with Defecation: Assess for distress during stooling, bleeding associated with hard stools, straining, poor appetite that improves after passing a large stool, and intermittent abdominal pain.
* Previous Health History: Document any past episodes of constipation, history of anal fissures, or painful bowel movements.
* Family and Social History: Note any familial gastrointestinal disorders and factors like diet, hydration, and activity levels that could influence bowel habits.
* Red Flags: Investigate potential underlying causes and symptoms like delayed passage of meconium, persistent pain, growth delays, or other significant findings from the clinical history that might indicate a systemic or anatomical issue.

Question 12

Physical Examination

Answer 12

• General Examination: Look for abdominal distension and evaluate the spine for irregularities.
• Anorectal Examination: Check for fissures, hemorrhoids, or signs of infection.
• Neuromuscular Function: Assess lower limb tone, strength, and reflexes to exclude neurological factors contributing to constipation.

Question 13

Investigations

Answer 13

=* Screening: Avoid invasive tests like endoscopy or extensive imaging unless symptoms persist or there are indications of underlying conditions.
* Targeted Investigations:
* Radiography: Employ abdominal radiographs to evaluate fecal load or structural anomalies when clinically indicated.
* Rectal Biopsy: Conduct if Hirschsprung’s disease is suspected based on clinical features.
* Blood Tests: Consider testing for celiac disease and hypothyroidism if symptoms like faltering growth or chronic constipation without clear cause are present.
* Anorectal Manometry: Useful in assessing anorectal function, particularly if neuromuscular dysfunction is suspected.
* Clinical Judgment
* Diagnosis: Combine findings from history, examination, and any performed tests to diagnose functional constipation.
* Exclusion of Other Causes: Carefully rule out metabolic, structural, or neurological conditions that could mimic or contribute to constipation symptoms.

Question 14

Diagnosis and Initial Assessment

Answer 14

1. History and Symptoms:
   * Document stool frequency, size, consistency, and any associated symptoms such as pain, straining, or bleeding.
   * Identify ‘red flag’ symptoms that may indicate an underlying condition needing specialist referral.
2. Physical Examination:
   * Check for abdominal distension and palpable fecal masses.
   * Examine the perianal area for abnormalities.

Question 15

Treatment Plan

Answer 15

Treatment Plan
1. Disimpaction:
* Start with polyethylene glycol (PEG) 3350 with electrolytes; escalate dose as needed.
* Add a stimulant laxative if there’s no improvement after two weeks.
* Consider enemas or manual removal under medical supervision if less invasive methods fail.
2. Maintenance Therapy:
* Continue with PEG, adjusting dosage based on stool consistency and symptom control.
* Use long-term laxatives as necessary, with plans for gradual weaning.
Dietary and Lifestyle Modifications
1. Diet:
* Increase fluid and fiber intake to ensure adequate hydration and a high-fiber diet.
2. Exercise:
* Encourage regular physical activity suitable for the child’s age.
3. Behavioral Modifications:
* Implement a structured toilet routine, employing incentives and educating about healthy bowel habits.
Monitoring and Follow-Up
* Conduct regular follow-ups to adjust treatment plans and ensure the efficacy and tolerance of the treatment.
* Educate the child and family about the nature of constipation, treatment expectations, and the importance of treatment compliance.

Question 16

Risks and Benefits of Treatments

Answer 16

• Benefits:
• Alleviates symptoms, prevents fecal impaction, and enhances quality of life.
• Primarily non-invasive, utilizing oral medications and lifestyle changes.
• Risks:
• Potential for electrolyte imbalances and dehydration from overuse of certain laxatives.
• Risk of dependency on laxatives for bowel movements.
• Psychological distress from invasive procedures like enemas.

Question 17

management Special Considerations

Answer 17

Special Considerations
* Psychological Support: Address emotional or behavioral issues associated with chronic constipation by involving psychological services.
* Tailored Approaches: Adapt the management plan based on individual responses and underlying health conditions, including considering advanced treatments like biofeedback or surgical interventions such as antegrade continence enema (ACE) for refractory cases.

Question 18

summary

Answer 18

appropriate medical interventions to optimize outcomes.
Diagnosis
1. Clinical History and Examination:
* Symptoms Assessment: Evaluate stool frequency, consistency, effort required to pass stools, and the presence of symptoms such as pain or bleeding.
* Physical Examination: Includes abdominal palpation for masses or tenderness and rectal examination for tone, stool presence, and anatomical abnormalities.
2. Diagnostic Tools:
* Digital Rectal Examination (DRE): Used selectively to identify conditions like Hirschsprung’s disease or anal fissures.
* Bristol Stool Form Scale: Helps categorize stool type to diagnose constipation severity and type.
* Laboratory Tests: Blood tests for underlying causes like hypothyroidism or celiac disease, based on clinical indications.
* Imaging and Specialized Tests:
* Radiographic Studies: Abdominal X-rays to assess fecal load and distribution.
* Rectal Biopsy: Conducted if Hirschsprung’s disease is suspected.
* Transit Studies: Differentiate between slow transit and normal transit constipation.
Management
1. Pharmacological Treatment:
* Laxatives: Use polyethylene glycol (PEG) for its safety and effectiveness; add stimulant laxatives like senna or bisacodyl if necessary.
* Stool Softeners: Such as docusate sodium to ease stool passage.
2. Dietary and Lifestyle Interventions:
* Diet: Increase fiber intake to enhance stool bulk and regularity.
* Hydration: Ensure adequate fluid intake to soften stools.
* Exercise: Encourage activities to promote gastrointestinal motility.
3. Behavioral Techniques:
* Scheduled Toileting: Use the natural gastrocolic reflex by encouraging toilet visits after meals.
Prognosis
1. Monitoring and Follow-Up:
* Regular assessments to adjust treatments based on patient response and prevent recurrence.
* Educational efforts to inform patients and caregivers about the nature of constipation, treatment expectations, and the importance of treatment adherence.
2. Long-term Management: Chronicity and Complications:
* Risk of Recurrence: High in patients with chronic constipation without changes in lifestyle or diet.
* Complications: Include hemorrhoids, anal fissures, and rectal prolapse due to chronic straining.
* Consider referrals to specialists for advanced management in refractory cases.
Utilizing Laboratory Sciences
* Pathophysiological Understanding: Applying knowledge of gastrointestinal transit and bowel movement mechanics to optimize treatment.
* Genetic and Microbiome Insights: Explore familial patterns and microbiome alterations to tailor interventions, including potential use of probiotics.

Question 19

• Faecal loading/impaction

Answer 19

• Faecal loading/impaction describes retention of faeces to the extent that spontaneous evacuation is unlikely.

Question 20

epidemelogy

Answer 20

Constipation is a common problem which can occur at any age. The reported prevalence rates vary due to differences in study populations and the definition used for constipation.
* A UK primary care cohort study found the prevalence of GP-diagnosed constipation was 12.8 per 1000 people [Shafe, 2011].
* A systematic review and meta-analysis of pooled, population-based cross-sectional studies found the global prevalence of constipation to vary according to which Rome criteria were used [Barberio, 2021].
o Prevalence was 15.3% with Rome I criteria, 11.2% with Rome II, 10.4% with Rome III and 10.1% with Rome IV criteria.
o The incidence of constipation is 2–3 times higher in women than in men, irrespective of the criteria used.
o Constipation is more common in the elderly — affecting 33.5% of people aged 60-101 years [Emmanuel, 2017].
o A higher prevalence is found in institutional settings. 30-40% have been found to have constipation living in their own home; over 50% of those living in nursing homes are affected and around 70% of people on long-stay wards are reported to have constipation.
o Constipation is more common during pregnancy than in the general population, affecting about 40% of women [UKTIS, 2013] — this may be due to physiological, biochemical, and dietary changes during pregnancy [Shi, 2015].
o Constipation is twice as likely in black patients and also in patients in deprived socio-economic groups [BMJ Best Practice, 2020].
* Note: the prevalence of constipation may be underestimated in studies due to the high proportion of people self-treating rather than consulting healthcare professionals [Tack, 2011].

Question 22

• Complications of chronic constipation include:

Answer 22

• Complications of chronic constipation include:
  o Faecal loading and impaction.
  o Progressive faecal retention, distension of the rectum, and loss of sensory and motor function.
  o Haemorrhoids or anal fissure.
  *=

Question 23

Complications of chronic faecal loading and impaction include:

Answer 23

Complications of chronic faecal loading and impaction include:
o Faecal incontinence, which can be embarrassing and distressing.
o Chronic dilatation of the colon may cause megacolon.
o Bowel obstruction, perforation, or ulceration.
o Recurrent urinary tract infections, obstructive uropathy.
o Rectal bleeding.
o Rectal prolapse.

Question 24

summary - paces

Answer 24

• Suspect a diagnosis of constipation if an adult presents with defecation which is problematic because of infrequent stools, difficulty passing stools, or a sensation of incomplete emptying or anorectal blockage.
  o Typically, bowel movements occurring less than three times a week may be regarded as constipation.
  o There may be daily bowel movements but associated symptoms such as excessive straining.
  o Additional symptoms may include lower abdominal pain or discomfort, distension, or bloating.
  o In practice constipation is often defined as passage of stools less frequently than the person’s normal pattern.
• Consider a diagnosis of constipation in the elderly if there are non-specific symptoms, such as:
  o Confusion or delirium, functional decline.
  o Nausea or loss of appetite.
  o Overflow diarrhoea.
  o Urinary retention.
• Suspect a diagnosis of faecal loading or impaction if there is history of:
  o Hard, lumpy stools, which may be large and infrequent (for example passed every 7–10 days), or small and relatively frequent (for example passed every 2–3 days).
  o Having to use manual methods to extract faeces.
  o Overflow faecal incontinence, or loose stool.
  If a diagnosis of constipation is suspected, ask about:
• Any red flag symptoms or signs that may suggest a serious underlying cause, such as colorectal cancer. These include a sudden change in bowel habit, rectal bleeding or bloody stools, weight loss, abdominal pain or iron deficiency anaemia. See the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for more information.
• What the person means by ‘constipation’ and their normal pattern of defecation.
  o The person’s perception of a normal bowel habit may influence the diagnosis of constipation.
• The duration of constipation, and the frequency and consistency of stools, such as hard/small (pebble-like) or large stools (for example, do they block the toilet); any nocturnal symptoms.
  o Consider the use of the Bristol Stool Chart to provide an objective record of the person’s stool form.
• Associated symptoms such as rectal discomfort, excessive straining, feeling of incomplete evacuation or blockage, or rectal bleeding; abdominal pain or distension.
  o Note: pelvic floor dyssynergia may be suggested by straining and a feeling of incomplete evacuation.
• Associated fever, nausea, vomiting, loss of appetite and/or weight.
• Associated urinary symptoms, urinary incontinence or retention, dyspareunia.
• Any family history of colorectal cancer or inflammatory bowel disease.
• How symptoms affect the person and impact on quality of life and daily functioning.
• Any self-help measures or drug treatments tried, including over-the-counter medication, and symptom response.
  To assess for any risk factors, ask about:
• The person’s diet, including fibre and fluid intake; normal routine or lifestyle; level of activity and mobility.
• The person’s toileting habits, for example feeling hurried or being disturbed when trying to defecate; withholding or ignoring the urge to defecate; access to the toilet at home or work, and level of privacy.
• Any associated psychological or mental health conditions, such as anxiety, depression, cognitive impairment, or an eating disorder.
• Any drug treatment or clinical features of an underlying organic cause of secondary constipation, and manage appropriately.
  To assess for faecal loading and/or impaction, ask about:
• A history of faecal incontinence, for example is underwear regularly soiled, excessive wiping, or loose stools.
• Whether the person has needed to use manual measures to relieve constipation:
  o A finger having to be inserted into the vagina suggests a rectocele.
  o A finger in the rectum to push away a flap suggests a rectal ulcer.
  o Pressure behind the anus may assist defecation if the levator muscles are weak.
  o Digital rectal evacuation of faeces confirms severe faecal loading and/or impaction.
  Examine the person:
• Assess for signs of weight loss and general nutritional status.
• Perform an abdominal examination to check for abdominal pain, distension, masses, or a palpable colon (suggesting retained faecal masses).
• Perform a digital rectal examination, checking for:
  o Anal fissures, haemorrhoids, skin tags, rectal prolapse, rectocele, skin erythema or excoriation (this may be a sign of faecal leakage).
  o Resting anal sphincter tone; rectal mass lesions and retained faecal masses, which may also be felt on external peri-anal palpation. Note: a faecal mass can be distinguished from a tumour or cyst, as firm pressure exerted by a finger will typically leave a palpable indentation in hard faeces.
  o Pelvic floor dysfunction (if appropriate) — while asking the person to ‘bear down’, there may be paradoxical contraction of the anal sphincter on straining.
  o Leakage of stool; rectal or anal pain.
  Be aware that no investigations are usually required in an adult with functional constipation where there is no suspected underlying cause.

Question 25

bristol stool type chart

Answer 25

Question 26

case history

Answer 26

Case history
Case history #1
A 5-month-old baby boy presents with difficulty and delay in passing hard stools. His mother reports
that he strains for several hours and may even miss a day, before passing stool with screaming and
occasional spots of fresh blood on the stool or nappy. He has recently been weaned from breastfeeding
to cows’ milk formula, which he had been reluctant to drink initially. The child is thriving and now feeding
normally. There was no neonatal delay in defecation and no history of excessive vomiting or abdominal
distension.
Case history #2
A 14-year-old girl, concerned about body image, altered her diet and decreased her oral intake hoping
to lose weight. Additionally, she avoided toilets at school due to their lack of cleanliness. She presented
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Constipation in children Theory
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to her paediatrician with the complaint of abdominal pain, distension, bloating, and difficult, painful
defecation.
Other presentations
In 90% to 95% of children with constipation, the problem is functional.[1] However, organic causes should
be considered in making this diagnosis. Chronic constipation may present after any cause of painful
defecation such as an anal fissure, perianal streptococcal infection, food intolerance (particularly cows’
milk allergy), lichen sclerosus, and penetrative child sexual abuse. Refusal to defecate may also be a
presentation of complex psychological problems, such as communication disorders that fall within the
autistic spectrum or children with attention deficit disorder.[2][3] Faecal incontinence in later childhood
may occur after poor sensory or behavioural response to faecal loading of the rectum secondary to
longstanding megarectum. Rarer causes of constipation include those presenting in the first weeks of
life, such as Hirschsprung’s disease or anorectal anomalies. In teenage years, abnormal diets as well as
eating disorders may lead to constipation.

Question 27

differentials

Answer 27

Question 28

ROME IV criteria

Answer 28

Constipation in childhood[38] [39]
Based on the ROME IV criteria. For diagnosis of functional constipation (i.e., no organic cause) in infants up
to 4 years of age, symptoms must include 1 month of at least 2 of the following:
* Two or fewer defecations per week
* History of excessive stool retention or retentive posturing
* History of painful or hard bowel movements
* Presence of a large faecal mass in the rectum
In toilet trained children, the following additional criteria may be used:
* History of large diameter stools that may obstruct the toilet
* At least 1 episode per week of faecal incontinence after the child has acquired toileting skills.
In children over 4 years old, symptoms should be present once a week for at least 1 month, with insufficient
criteria for the diagnosis of irritable bowel syndrome.