Bowel Disorders: Chronic Constipation

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patient with infrequent, and/or hard stools and/or difficult to pass stools when not on laxatives
history and physical examination
alarm features?
symptom improvement?
refer for consideration of physiological assessment (anorectal function, colonic transit); see ’refractory constipation and difficult defecation’ algorithm
any abnormality identified?
investigations as indicated eg. colonoscopy, metabolic screen
colorectal cancer or other obstructing lesion, anorectal disease, hypothyroidism, hypercalcemia
formulate longer term management plan
constipating drugs?
explanation physiology, modify life style & diet, discuss bulking agents, simple laxatives
stop drugs if possible
drug-induced constipation
symptom improvement?
functional constipation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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Case History - Chronic Constipation

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A 40 year-old hairdresser is referred to a gastroenterologist by her primary care physician because of longstanding infrequent hard stools (Box 1, Figure 3). She defecates on average twice a week, and on most occasions this requires considerable straining. The stools consist of small hard pellets, never loose and watery unless she uses laxatives. The gastroenterologist shows the patient the BSFS, and the patient indicates that her stools usually conform to stool type 1 or 2 of the BSFS. These symptoms have been present for eight years, but have become gradually more severe and troublesome over the last two. She denies the need to manually disimpact herself, and does not describe a sensation of something blocking the passage of the stool. There is no abdominal pain, but she experiences abdominal bloating several times a week (Box 2). She has had no weight loss (Box 3). Her periods are very heavy and last 7 days. She smokes five cigarettes daily and does not drink alcohol. She takes no constipating drugs (Box 7). She has two children, both delivered vaginally without complication. She denies depression and describes an active social life. Dietary review indicates her fiber intake to be 15 to 20 g daily. There is nothing relevant in her past medical history, and no family history of constipation, bowel cancer or other gastrointestinal disease.

Physical examination is negative, including the abdominal exam. Small hemorrhoids are evident on anal inspection, and digital rectal examination reveals only hard stool. In particular, anal sphincter tone is normal, and simulated evacuation is accompanied by relaxation of the puborectalis muscle with normal perineal descent (Box 2). The patient has tried a number of over-the-counter preparations, including stool softeners and herbal teas, but these have not been very effective. Recently, she has found that if she takes two bisacodyl tablets in the morning, she can sometimes have a more complete motion later in the day, but the improvement is short-lived.

A CBC is normal. In the absence of evidence suggesting pelvic floor dysfunction or colonic inertia (see ’refractory constipation and difficult defecation’ algorithm following), the gastroenterologist makes a diagnosis of functional constipation (Box 11) He explains the possible mechanisms for the constipation, and suggests that she gradually increase her dietary fiber intake, and commence a low dose of psyllium, slowly increasing this over several months with adequate fluid intake (Box 12). He indicates she may add a polyethylene glycol (PEG) preparation if needed. Three months later, she reports significant improvement in her stool form and straining, and she defecates 3 or 4 times weekly (Box 13). She has been taking psyllium on a regular basis, with the addition of a PEG preparation as required, and is happy to continue to do this in the longer term (Box 14).

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