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Definition :

  • The infrequent passage of hard stools is called the Constipation.
  • The chief complaints of the patient’s are straining, a sensation of incomplete evacuation and also perianal or abdominal discomfort.

Causes :

  • Gastrointestinal causes :
    • Due to lack of fibre and fluid intake.
    • It may also be due to slow-transit time, irritable bowel syndrome, chronic intestinal pseudo obstruction and may also be due to some drugs.
    • Structural causes includes Colonic carcinoma, Hirschsprung’s disease and also diverticular disease.
    • Constipation may also be the secondary cause occuring due to Anorectal disease and obstructed defaecation.
  • Non-gatrointestinal causes :
    • It may be due to intake of certain drugs like Opiates, Iron supplements, Anticholinergics, Aluminium containing antacids and also calcium antagonists.
    • Neurological causes includes Multiple sclerosis, Cerebrovascular accidents, Spinal cord lesions, Parkinsonism.
  • Metabolic and endocrine causes :
    • These include Diabetes mellitus, Hypothyroidism, Hypercalcaemia and also Pregnancy.
  • Other causes includes Depression and any other serious illness with immobility particularly in elderly people.

Types of constipation :

  • Simple
  • Severe Idiopathic
  • Constipation of faecal impaction

Simple constipation :

  • Simple type is extremely common and also it does not signify any underlying organic disorder.
  • It usually responds to the increased fluid intake, dietary fibre intake and also to bulking agents.
  • Moreover many types of laxatives are available.

Class Examples
Bulk-forming laxatives Ispaghula husk, methylcellulose
Stimulants Bisacodyl, Dantron (only for terminally ill patients), docusate, senna
Faecal softeners Docusate, Arachis oil enema
Osmotic laxatives Lactulose, Lactitol, Magnesium salts
Others Polythylene glycol, phosphate enema

Severe idiopathic constipation :

  • Occurs exclusively in young women and also often in adolescence.
  • The cause is usually unknown.
  • But some womens are tend to have obstructed bowel.
  • Some women tend to have obstructed defaecation resulting from inappropriate contraction of the external anal spincter and puborectalis muscle.
  • The above condition is often resistant to treatment.
  • Bulking agents tend to exacerbate the condition.
  • But prokinetic agents or balanced solutions of polyethylene glycol benefit some patients with slow transit.
  • Glycerol suppositories and biofeedback techniques are used for people with obstructed defaecation.
  • Other people benefit from Prucalopride or Linaclotide.
  • Rarely, subtotal colectomy may be necessary for the patients with idiopathic constipation.

Faecal impact :

  • In faecal impact a large mass of faecal matters tend to accumulate in the rectal portion.
  • This tends to occur in immobile, institutional or disabled patients.
  • Moreover this occurs mostly in the elderly patients.
  • Perforation and bleeding from pressure induced ulceration are occassionally seen.
  • Treatment involves adequate hydration and careful digital disimpaction after softening the disimpacted stool with arachis oil enemas.
  • Stimulants should also be avoided.

Clinical assessment and management :

  • The onset, duration and also characteristics are most important.
  • For example, a neonatal onset suggests a Hirchsprung’s disease, while a recent change in the bowel activity suggests the suspicion of an organic disorder such as colonic carcinoma.
  • The presence of weight loss, rectal bleeding is important as are excessive straining symptoms suggestive of irritable bowel syndrome. a history of childhood constipation and emotional distress.

Constipation - Laxatives

Initial visit to the hospital :

  • Digital rectal examination
  • Proctoscopy
  • Sigmoidoscopy
  • Routine biochemistry – Serum calcium, Thyroid function test, Full blood count.
  • If these are found to be normal then 1-month trial of dietary fibre and/or laxatives is justified.

Next visit :

  • If symptoms persists, then examination of colon by Barium enema or CT colography is indiacted to look for structural disease.

Further investigation :

  • Intestinal marker studies
  • Anorectal manometry
  • Electrophysiological studies and also
  • Magnetic resonance proctography can all be used to define the problem.

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