Post on 10-Jul-2015
A 55 y/o women requested your consultationbecause of change in her bowel movements.Since about 6 months, she experiencesinfrequent passage of stools and hard stools; shedenies diarrhea or rectal bleeding. Her weight isstable and her appetite is unchanged. She eats 3meals per day. But she admitted consuming littledietary fiber. her previous medical history isuneventful. However she worried because afriend diagnosed with colonic carcinoma. A nieceof her uses a thyroid hormone preparation forhypothyroidism.
Case 1A
A 55 y/o women requested your consultationbecause of change in her bowel movements.Since about 6 months, she experiencesinfrequent passage of stools and hard stools; shedenies diarrhea or rectal bleeding. Her weight isstable and her appetite is unchanged. She eats 3meals per day. But she admitted consuming littledietary fiber. her previous medical history isuneventful. However she worried because afriend diagnosed with colonic carcinoma. A nieceof her uses a thyroid hormone preparation forhypothyroidism.
Case 1A
OBJs
1- Which further issues need to be clarified before you can diagnose constipation in this patients?
2- What do you expect in physical examination?
Introduction
Constipation is a common complaint, especially in women and older adults. It results in millions of physician visits per year, with hundreds of millions of dollars spent on laxatives. Untreated it can lead to serious morbidity and can be a contributing factor in mortality. A rational approach to the patient presenting with constipation includes a detailed history, general and focused physical examination, specific investigations, and appropriate therapy.
What is constipation?
Constipation is difficult or infrequent bowel movements, hard stool, or a feeling that the rectum is not totally empty after a bowel movement.
The patient's view
• Infrequent passage of stools <3 times per week
• Straining >25% of time
• Passage of hard stools
• Incomplete evacuation and sensation of anorectal blockage
Rome III criteriaHaving 2 or more of the following for at least 12 ws
The clinical view
Risk factorsThe following factors can increase a person’s likelihood of
becoming constipated;
1. Female gender
2. Over 65 years of age
3. Low caloric intake (eating less food)
4. Greater number of medications used
5. Sedentary lifestyle (lack of exercise)
6. Ignoring the urge to defecate
1. Distended, swollen abdomen
2. Vomiting
3. Blood in stool
4. Weight loss
5. New/worsening severe constipation in older people
Not every episode of constipation requires immediate
evaluation by a doctor.
Warning symptoms
Stool
Bleeding
Age of onset
Other symptoms
Pain
Diet Drug
Urge present
Aggravating factors
History taking
Physical Examination•Inspection
•Abnormal appearance/position/patency of anus
•Abdominal examination
Gross abdominal distension
•Spine/lumbosacral region/gluteal examination
abnormal
•Lower limb
Deformity/abnormal neuromuscular exam/abnormal reflexes
• Rectal examination
presence of hemorrhoids, admixture of blood tumors, polyps
Summary
• Constipation is very common in women and elderly
• There are many causes of constipation; it should be considered a symptom, not
a disease.
• History taking
• Physical examination
References
1. NICE guidelines, May 2010, Constipation in children and young
people: Diagnosis and management of idiopathic childhood
constipation in primary and secondary care
2. Merck manual
3. Kumar and Clark