Constipation
Constipation is defined as small, infrequent, or difficult bowel movements. Because normal bowel movements can vary in frequency and from individual to individual, constipation is relative and must be determined in relation to the patient's normal elimination pattern. Constipation may be a minor annoyance or, uncommonly, a sign of a life-threatening disorder such as an acute intestinal obstruction. Untreated, constipation can lead to headache, anorexia, and abdominal discomfort and can adversely affect the patient's lifestyle and well-being.
Constipation usually occurs when the urge to defecate is suppressed and the muscles associated with bowel movements remain contracted. Because the autonomic nervous system controls bowel movements — by sensing rectal distention from fecal contents and by stimulating the external sphincter — any factor that influences this system may cause bowel dysfunction. (See How habits and stress cause constipation.)
History and physical examination
Ask the patient to describe the frequency of his bowel movements and the size and consistency of his stools. How long has he had constipation? Acute constipation usually has a physiological cause such as an anal or rectal disorder. In a patient older than age 45, a recent onset of constipation may be an early sign of colorectal cancer. Conversely, chronic constipation typically has a functional cause and may be related to stress.
Does the patient have pain related to constipation? If so, when did he first notice the pain, and where is it located? Cramping abdominal pain and distention suggest obstipation — extreme, persistent constipation due to intestinal tract obstruction. Ask the patient if defecation worsens or helps relieve the pain. Defecation usually worsens pain, but with such disorders as irritable bowel syndrome, it may relieve it.
Ask the patient to describe a typical day's diet; estimate his daily fiber and fluid intake. Ask him about changes in eating habits, medication or alcohol use, or physical activity. Has he experienced recent emotional distress? Has constipation affected his family life or social contacts? Also, ask about his job and exercise pattern. A sedentary or stressful job can contribute to constipation.
Find out whether the patient has a history of GI, rectoanal, neurologic, or metabolic disorders; abdominal surgery; or radiation therapy. Then ask about the medications he's taking, including opioids and over-the-counter preparations, such as laxatives, mineral oil, stool softeners, and enemas.
Inspect the abdomen for distention or scars from previous surgery. Then auscultate for bowel sounds, and characterize their motility. Percuss all four quadrants, and gently palpate for abdominal tenderness, a palpable mass, and hepatomegaly. Next, examine the patient's rectum. Spread his buttocks to expose the anus, and inspect for inflammation, lesions, scars, fissures, and external hemorrhoids. Use a disposable glove and lubricant to palpate the anal sphincter for laxity or stricture. Also, palpate for rectal masses and fecal impaction. Finally, obtain a stool sample and test it for occult blood.
As you assess the patient, remember that constipation can result from several life-threatening disorders, such as an acute intestinal obstruction and mesenteric artery ischemia, but it doesn't herald these conditions.
Medical causes
Anal fissure.
A crack or laceration in the lining of the anal wall can cause acute constipation, usually due to the patient's fear of the severe tearing or burning pain associated with bowel movements. He may notice a few drops of blood streaking toilet tissue or his underwear.
Anorectal abscess.
In anorectal abscess, constipation occurs together with severe, throbbing, localized pain and tenderness at the abscess site. The patient may also have localized inflammation, swelling, and purulent drainage and may complain of fever and malaise.
Cirrhosis.
In the early stages of cirrhosis, the patient experiences constipation along with nausea and vomiting and a dull pain in the right upper quadrant. Other early findings include indigestion, anorexia, fatigue, malaise, flatulence, hepatomegaly and, possibly, splenomegaly and diarrhea.
Diabetic neuropathy.
Diabetic neuropathy produces episodic constipation or diarrhea. Other signs and symptoms include dysphagia, orthostatic hypotension, syncope, and painless bladder distention with overflow incontinence. A male patient may also experience impotence and retrograde ejaculation.
Diverticulitis.
In diverticulitis, constipation or diarrhea occurs with left lower quadrant pain and tenderness and possibly a palpable, tender, firm, fixed abdominal mass. The patient may develop mild nausea, flatulence, or a low-grade fever.
Hemorrhoids.
Thrombosed hemorrhoids cause constipation as the patient tries to avoid the severe pain of defecation. The hemorrhoids may bleed during defecation.
Hepatic porphyria.
Abdominal pain, which may be severe, colicky, localized, or generalized, precedes constipation in hepatic porphyria. The patient may also have a fever, sinus tachycardia, labile hypertension, excessive diaphoresis, severe vomiting, photophobia, urine retention, nervousness or restlessness, disorientation and, possibly, visual hallucinations. Deep tendon reflexes may be diminished or absent. He may also have skin lesions causing itching, burning, erythema, altered pigmentation, and edema in areas exposed to light. Severe hepatic porphyria can produce delirium, coma, seizures, paraplegia, or complete flaccid quadriplegia.
Hypercalcemia.
With hypercalcemia, constipation usually occurs along with anorexia, nausea, vomiting, polyuria, and polydipsia. The patient may also display arrhythmias, bone pain, muscle weakness and atrophy, hypoactive deep tendon reflexes, and personality changes.
Hypothyroidism.
Constipation occurs early and insidiously in patients with hypothyroidism, in addition to fatigue, sensitivity to cold, anorexia with weight gain, menorrhagia in women, decreased memory, hearing impairment, muscle cramps, and paresthesia.
Intestinal obstruction.
Constipation associated with an intestinal obstruction varies in severity and onset, depending on the location and extent of the obstruction. With partial obstruction, constipation may alternate with leakage of liquid stools. With complete obstruction, obstipation may occur. Constipation can be the earliest sign of partial colon obstruction, but it usually occurs later if the level of the obstruction is more proximal. Associated findings include episodes of colicky abdominal pain, abdominal distention, nausea, or vomiting. The patient may also develop hyperactive bowel sounds, visible peristaltic waves, a palpable abdominal mass, and abdominal tenderness.
Irritable bowel syndrome (IBS).
IBS commonly produces chronic constipation, although some patients have intermittent, watery diarrhea and others complain of alternating constipation and diarrhea. Stress may trigger nausea and abdominal distention and tenderness, but defecation usually relieves these signs and symptoms. Patients typically have an intense urge to defecate and feelings of incomplete evacuation. Typically, the stools are scybalous and contain visible mucus.
Mesenteric artery ischemia.
Mesenteric artery ischemia is a life-threatening disorder that produces sudden constipation with failure to expel stool or flatus. Initially, the abdomen is soft and nontender, but soon severe abdominal pain, tenderness, vomiting, and anorexia occur. Later, the patient may develop abdominal guarding, rigidity, and distention; tachycardia; syncope; tachypnea; a fever; and signs of shock, such as cool, clammy skin and hypotension. A bruit may be heard.
Spinal cord lesion.
Constipation may occur with a spinal cord lesion, in addition to urine retention, sexual dysfunction, pain and, possibly, motor weakness, paralysis, or sensory impairment below the level of the lesion.
Other causes
Diagnostic tests.
Constipation can result from the retention of barium given during certain GI studies.
Drugs.
Patients commonly experience constipation when taking an opioid analgesic or other drugs, including vinca alkaloids, calcium channel blockers, antacids containing aluminum or calcium, anticholinergics, and drugs with anticholinergic effects (such as tricyclic antidepressants). Patients may also experience constipation from excessive use of laxatives or enemas.
Surgery and radiation therapy.
Constipation can result from rectoanal surgery, which may traumatize nerves, and abdominal irradiation, which may cause intestinal stricture.
Special considerations
As indicated, prepare the patient for diagnostic tests, such as proctosigmoidoscopy, colonoscopy, barium enema, plain abdominal films, and an upper GI series. If the patient is on bed rest, reposition him frequently, and help him perform active or passive exercises, as indicated. Teach abdominal toning exercises if the patient's abdominal muscles are weak and relaxation techniques to help him reduce stress related to constipation.
Pediatric pointers
The high content of casein and calcium in cow's milk can produce hard stools and possible constipation in bottle-fed infants. Other causes of constipation in infants include inadequate fluid intake, Hirschsprung's disease, and anal fissures. In older children, constipation usually results from inadequate fiber intake and excessive intake of milk; it can also result from bowel spasm, mechanical obstruction, hypothyroidism, a reluctance to stop playing for bathroom breaks, and the lack of privacy in some school bathrooms.
Geriatric pointers
Acute constipation in elderly patients is usually associated with underlying structural abnormalities. Chronic constipation, however, is chiefly caused by lifelong bowel and dietary habits and laxative use.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
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» Next page: Peristaltic waves, visible (Handbook of Signs & Symptoms (Third Edition))
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