CONSTIPATION

A condition characterised by hardened faeces and difficulty emptying the bowels

Causes

  • Dietary: lack of roughage, inadequate fluid intake
  • In infants: concentrated feeds
  • Lack of exercise, bedridden patient especially in elderly
  • Pregnancy
  • Certain drugs e.g. narcotic analgesics, antidepressants, diuretics, antipsychotics, iron
  • Colon or anorectal disorders : stricture, cancer, fissure, proctitis , congenital bowel abnormalities, irritable bowel syndrome, volvulus, intussusception
  • Metabolic : hypercalcemia, diabetes, hypothyroidism
  • Neurological disorders: spinal cord lesions, stroke, Parkinsonism

Clinical features

  • Abdominal discomfort
  • Small hard stools passed irregularly under strain
  • Can cause haemorrhoids and anal fissure

Alarm features

  • Symptoms and signs of intestinal obstruction or acute abdomen
  • Confusion/disorientation
  • Abnormal vital signs
  • Iron deficiency
  • Rectal bleeding or haematochesia or rectal mass
  • Haem postive stool
  • Patients > 45 years with no previous history of colon cancer screening
  • History of colon cancer in immediate family relatives
  • Weight loss

Investigations

  • Physical examination
    • Abdominal mass and tenderness
    • Anorectal examination (faecal impaction, stricture, rectal prolapse, rectal mass)
  • Stool examination

Investigations for patients with alarm features

  • Abdominal series (supine, upright, left lateral decubitus)
  • Transabdominal ultrasound
  • Endoscopy
  • Complete blood count, renal function tests, serum calcium, thyroid function tests, blood sugar
  • Barium enema +/- CT scan or X-ray

Management

No alarm features or chronic constipation

  • High dietary fibre
  • Adequate fluid intake
  • Bisacodyl: Adult 10 mg at night. Take until stool is passed
    Child 5-12 years: 5 mg (suppository only)

    • Contraindicated in acute abdomen as it aggravates the condition
  • Oral or rectal lactulose (osmotic agent). Provides faster relief than bisacodyl

If alarm features or severe chronic constipation are present

  • Refer to hospital for specialist management

Prevention

  • Diet rich in roughage – plenty of vegetables and fruit
  • Plenty of oral fluids with meals
  • Increased exercise