Symptom Finder - Constipation
CONSTIPATION
The causes of constipation can be recalled on a physiologic basis. Normal defecation requires feces that are of proper consistency, good muscular contraction of the walls of the large intestine, and unobstructed passage of the stool. It follows that constipation will result from insufficient intake of food and water, inhibition of muscular contraction of the bowels, or obstruction to the passage of stools. The obstruction can be high or low
and intrinsic or extrinsic.
1. Insufficient intake of food and water: Starvation or anything that interferes with the appetite will cause constipation. Senility, anorexia nervosa, chronic tonsillitis, and cardiospasm of the esophagus are examples. Lack of fluid intake will cause a hard
stool and constipation.
2. Poor bowel motility and contractility: Neurologic conditions such as poliomyelitis and tabes dorsalis may be considered in this group. In Hirschsprung disease, there is lack of the myenteric plexus, causing poor contraction of the bowel wall. Anxiety and depression may interfere with bowel motility and lead to constipation. Certain drugs (such as atropine derivatives, tranquilizers, opiates, and barbiturates) interfere with bowel motility and cause constipation. Uremia and diabetic acidosis may cause a paralytic ileus.
3. Obstruction:
A. High obstruction includes pyloric stenosis, volvulus, intussusception, regional ileitis, adhesions, and incarcerated hernias.
B. Low obstruction includes intrinsic lesions such as polyps, carcinomas, fecal impactions, and conditions that cause spasm of the rectal sphincter, such as proctitis, hemorrhoids, rectal fissures, rectal fistulas, and abscesses and spinal cord lesions like multiple sclerosis.
C. Extrinsic conditions that cause low obstructions include pelvic inflammatory disease, a retroverted uterus, endometriosis, pregnancy, fibroids, ovarian cysts, and a
large prostate or pelvic abscess.
Approach to the Diagnosis
If the constipation is acute a CT scan and surgical consult would be indicated. For chronic constipation a rectal examination for a fecal impaction and subsequent enemas are the first steps if no contraindication exists. This may disclose a fissure, inflamed hemorrhoid, or abscess. Pelvic examination must be done in all female patients. If nothing is found here a colonoscopy examination or proctoscopy and barium enema would be indicated, provided the neurologic examination and a flat plate of the abdomen are normal. Careful inquiry about diet, drugs, and emotional stress should be made.
Other Useful Tests
1. Glucose tolerance test (diabetic neuropathy)
2. Stool for occult blood (rectal or colon carcinoma)
230
3. Serum electrolytes (motility disorder)
4. Thyroid function tests (hypothyroidism)
5. Urine porphobilinogen (porphyria)
6. Urine drug screen (drug abuse)
7. Colonoscopy (colon carcinoma)
8. Defecography (motility disorder)
9. Anorectal manometry (neuropathy)
10. Gastroenterology consult
11. Psychometric testing
12. Therapeutic trial of stool softeners or psyllium fibers
The causes of constipation can be recalled on a physiologic basis. Normal defecation requires feces that are of proper consistency, good muscular contraction of the walls of the large intestine, and unobstructed passage of the stool. It follows that constipation will result from insufficient intake of food and water, inhibition of muscular contraction of the bowels, or obstruction to the passage of stools. The obstruction can be high or low
and intrinsic or extrinsic.
1. Insufficient intake of food and water: Starvation or anything that interferes with the appetite will cause constipation. Senility, anorexia nervosa, chronic tonsillitis, and cardiospasm of the esophagus are examples. Lack of fluid intake will cause a hard
stool and constipation.
2. Poor bowel motility and contractility: Neurologic conditions such as poliomyelitis and tabes dorsalis may be considered in this group. In Hirschsprung disease, there is lack of the myenteric plexus, causing poor contraction of the bowel wall. Anxiety and depression may interfere with bowel motility and lead to constipation. Certain drugs (such as atropine derivatives, tranquilizers, opiates, and barbiturates) interfere with bowel motility and cause constipation. Uremia and diabetic acidosis may cause a paralytic ileus.
3. Obstruction:
A. High obstruction includes pyloric stenosis, volvulus, intussusception, regional ileitis, adhesions, and incarcerated hernias.
B. Low obstruction includes intrinsic lesions such as polyps, carcinomas, fecal impactions, and conditions that cause spasm of the rectal sphincter, such as proctitis, hemorrhoids, rectal fissures, rectal fistulas, and abscesses and spinal cord lesions like multiple sclerosis.
C. Extrinsic conditions that cause low obstructions include pelvic inflammatory disease, a retroverted uterus, endometriosis, pregnancy, fibroids, ovarian cysts, and a
large prostate or pelvic abscess.
Approach to the Diagnosis
If the constipation is acute a CT scan and surgical consult would be indicated. For chronic constipation a rectal examination for a fecal impaction and subsequent enemas are the first steps if no contraindication exists. This may disclose a fissure, inflamed hemorrhoid, or abscess. Pelvic examination must be done in all female patients. If nothing is found here a colonoscopy examination or proctoscopy and barium enema would be indicated, provided the neurologic examination and a flat plate of the abdomen are normal. Careful inquiry about diet, drugs, and emotional stress should be made.
Other Useful Tests
1. Glucose tolerance test (diabetic neuropathy)
2. Stool for occult blood (rectal or colon carcinoma)
230
3. Serum electrolytes (motility disorder)
4. Thyroid function tests (hypothyroidism)
5. Urine porphobilinogen (porphyria)
6. Urine drug screen (drug abuse)
7. Colonoscopy (colon carcinoma)
8. Defecography (motility disorder)
9. Anorectal manometry (neuropathy)
10. Gastroenterology consult
11. Psychometric testing
12. Therapeutic trial of stool softeners or psyllium fibers
