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INTRODUCTION

  • Constipation has been defined as difficult or infrequent passage of stool, at times associated with straining or a feeling of incomplete defecation. The condition is considered chronic if symptoms last for at least 3 months.

PATHOPHYSIOLOGY

  • Constipation may be primary (occurs without an underlying identifiable cause) or secondary (the result of constipating drugs, lifestyle factors, or medical disorders).

  • Constipation commonly results from a diet low in fiber, inadequate fluid intake, decreased physical activity, or from use of constipating drugs such as opioids.

  • Diseases or conditions that may cause constipation include the following:

    • ✔ Gastrointestinal (GI) disorders: Irritable bowel syndrome (IBS), diverticulitis, upper and lower GI tract diseases, hemorrhoids, anal fissures, ulcerative proctitis, tumors, hernia, volvulus of the bowel, syphilis, tuberculosis, lymphogranuloma venereum, and Hirschsprung disease

    • ✔ Metabolic and endocrine disorders: Diabetes mellitus with neuropathy, hypothyroidism, panhypopituitarism, pheochromocytoma, hypercalcemia, and enteric glucagon excess

    • ✔ Pregnancy

    • ✔ Cardiac disorders (eg, heart failure)

    • ✔ Neurogenic constipation: Head trauma, CNS tumors, spinal cord injury, cerebrospinal accidents, and Parkinson disease

    • ✔ Psychogenic causes such as ignoring or postponing the urge to defecate and psychiatric diseases

  • Causes of drug-induced constipation are listed in Table 22-1. All opioid derivatives are associated with constipation, but the degree of intestinal inhibitory effects seems to differ among agents. Orally administered opioids appear to have a greater inhibitory effect than parenterally administered agents.

TABLE 22-1Drugs Causing Constipation

CLINICAL PRESENTATION

  • Table 22-2 shows the general clinical presentation of constipation. According to the Rome IV criteria patients should have at least two of the signs and symptoms listed in Table 22-2 apply to a minimum of 25% of bowel movements.

  • A complete and thorough history should be obtained from the patient, including frequency of bowel movements and duration of symptoms. The patient should also be carefully questioned about usual diet and laxative regimens.

  • General health status, signs of underlying medical illness (ie, hypothyroidism), and psychological status (eg, depression or other psychological illness) should be assessed.

  • Patients with “alarm symptoms,” a family history of colon cancer, or those older than 50 years with new symptoms may need further diagnostic evaluation.

TABLE 22-2Clinical Presentation of Constipation

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