Constipation

Constipation is the infrequent passage of stool. It is generally defined as ≤ 3 bowel movements per week, which may be associated with straining to defecate, the passage of hard stools, tenesmus, or the need for self-digitation to evacuate stool. It may be primary or secondary. Types of primary constipation (i.e., no identifiable organic cause) include normal transit constipation (e.g., due to inadequate calorie, fiber, or water intake), slow transit constipation, and pelvic floor dyssynergia. Secondary constipation may be drug-induced (e.g., opioid-induced constipation) or due to metabolic disorders (e.g., hypothyroidism), neurological disorders (e.g., spinal cord lesion), or mechanical obstruction of the bowel (e.g., colon cancer). Any identifiable underlying cause should be managed accordingly. In the absence of organic disease, constipation may resolve with regular exercise, hydration, and fiber supplementation. Osmotic or secretory laxatives may be considered in patients with persisting constipation. Long-term use of laxatives may result in dependency and paradoxical constipation.

• Prevalence: ∼ 14% of the general population experiences chronic constipation. ^[1]
• Sex: ♀ > ♂ (3:1) ^[2]
• Accounts for 3–5% of pediatric outpatient visits ^[3]

Epidemiological data refers to the US, unless otherwise specified.

• Primary constipation (functional constipation)
  • Most commonly due to poor diet and insufficient exercise
  • In children: typically occurs during weaning, the toilet training phase, or once attending school (because of avoidance of school toilets) ^[3]
• Secondary constipation: See differential diagnoses below.

References:^[2][3][4]

Both primary and secondary constipation can cause changes in stool consistency and defecation habits.

• Mechanism of altered stool consistency
  • External factors such as lack of exercise or inadequate fluid and fiber intake (primary constipation)/internal factors such as changes within the colon or rectum (secondary constipation) → slow passage of stool → prolonged absorption of water by the bowel → dry, hard stool → painful defecation → sensation of incomplete and irregular bowel emptying → constipation
• Mechanism of altered bowel motility
  • Effective peristalsis of the bowel is controlled by intrinsic (e.g., myenteric plexus) and extrinsic (e.g., sympathetic and parasympathetic) innervation.
  • Any alteration in bowel innervation may lead to ineffective peristalsis.
    • Drugs (e.g., calcium channel blockers, opiates, antispasmodics, antidepressants) ^[5] → altered autonomic outflow and bowel muscle contraction ^[6]
    • Endocrine pathology (e.g., hypothyroidism) → downregulated bowel motility
    • Neurological pathology (e.g., spinal injury, enteric neuropathy) → disease or trauma of bowel innervation
  • Ineffective peristalsis → difficult passage of stool regardless of stool consistency → sensation of incomplete and irregular bowel emptying

References:^[3][5][6][7]

Constipation is a clinical diagnosis and laboratory tests and imaging are not routinely indicated. Indications for diagnostics include the presence of any red flags (see below) or a suspected secondary cause of constipation, such as hypothyroidism.

Patient history

• Ask about dietary habits, medication use, mobility, stool character and frequency, problems with defecation, and anorectal pain.
• Additionally in children: delayed passage of meconium (e.g., Hirschsprung disease), voluntary withholding of stool (e.g., squatting, crying, crossing ankles, hiding), fecal (overflow) incontinence

Physical examination

• Inspect the anorectal area.
  • Possible fissures
  • Hemorrhoids
  • Check the anal wink reflex : An absent anal wink reflex suggests a pathology (e.g., sacral nerve injury). ^[4][8]
• Digital examination of the rectum
  • Check for rectal carcinoma.
  • Test the sphincter tone to evaluate for pelvic floor dysfunction.

Additional investigations

• Laboratory investigations: exclude hypokalemia, hypothyroidism, diabetes mellitus
• Imaging: abdominal x-ray ^[2]
• Colonoscopy: : to exclude mechanical obstruction; (e.g., tumor, stenosis), especially in the presence of red flags (see table below) ^[2][4][5]

In patients with no red flag features, laboratory tests and imaging are not routinely recommended.

Red flags in patients with constipation

A change in stool caliber (i.e., pencil-thin stool) and/or rectal bleeding in any patient > 50 years of age must be further investigated, as these features may be signs of colorectal cancer!

Acute-onset constipation should raise suspicion for bowel obstruction!

References:^{[2][3][4][5][8][9][10]}

• Identify and treat any underlying conditions (see differential diagnoses).
• Approach in adults ^[11]
  • Begin with lifestyle changes: high-fiber diet; , increased fluid intake; , and exercise
  • If constipation persists, start an osmotic laxative (e.g., polyethylene glycol ).
  • If osmotic laxatives are unsuccessful, add a stimulant laxative (e.g., senna or bisacodyl ).
• Approach in children ^[3][9]
  • Infants 2 weeks to 6 months of age, without alarming features
    • May only require reassurance
      • Passage of stool is particularly variable in breastfed infants.
      • Parents who formula feed their children should be properly instructed on correct formula preparation.
    • Reassess in 2–4 weeks. ^[9]
    • If constipation persists, consider drug therapy (best initial: polyethylene glycol).
  • Children ≥ 6 months of age without suspected organic disease
    • Prompt laxative therapy (best initial: polyethylene glycol)
    • In combination with age-appropriate fiber, fluid, and physical activity requirements
    • Toilet training, if applicable ^[12]
  • Maintenance therapy: laxative therapy (polyethylene glycol or lactulose) until constipation is resolved for at least 1 month (treatment should then be tapered gradually) ^[9]
  • Further investigation to exclude an underlying disorder is warranted if there is a poor response to the treatments mentioned above or if constipation affects a child < 2 weeks of age.

References:^{[3][9][12][13][14]}

• Rule out life-threatening causes (e.g., mechanical bowel obstruction, toxic megacolon).
• Identify and treat the underlying cause.
• Discontinue any contributing medications (if appropriate)
• Encourage PO fluid intake (2–3 L/day).
• Start high-fiber diet (20–35 g/day). ^[15]
• Encourage the consumption of vegetables, fruits (especially prunes), legumes, oats, rye, nuts, and seeds.
• Mobilize patient/encourage ambulation.
• Schedule regular toileting.
• Start laxative therapy.

• Fecal incontinence
• Fecal impaction
• Anal fissures
• Hemorrhoids
• Megacolon
• Urinary retention
• Pelvic floor damage in women

References:^[2]

We list the most important complications. The selection is not exhaustive.

Clinical features

• Inability to defecate for days or weeks
• Normal bowel sounds
• Distended, tympanitic abdomen
• DRE: hard, impacted stools distending the rectum
• Tenesmus

Diagnostics

• Clinical diagnosis
• Abdominal x-ray (to rule out bowel perforation)
  • Findings:
    • Dilated bowel loops
    • Fecal shadows in the colon and rectum
    • Air-fluid levels may be visible.

Treatment ^[16][17]

• Rule out bowel perforation.
• Manual disimpaction
• Administer osmotic enema (e.g., warm water enema or mineral oil enema).
• Consider the addition of stimulatory suppositories
  • Bisacodyl suppository
  • Glycerine suppository
• Prevention of recurrence
  • Start maintenance bowel regimen with osmotic laxative (e.g., polyethylene glycol or lactulose ).
  • Stop contributing medications.
  • Lifestyle modifications
  • See “Treatment.”
• For severe cases, consult surgery.

Avoid phosphate-based enemas in elderly patients due to the risk of severe electrolyte abnormalities. ^[18]

Clinical features

• Recent initiation of an opioid or dose adjustment
• New or worsening constipation
• Fecal impaction may be present
• Physical examination typically normal

Diagnostics ^[19]

• Clinical diagnosis
• Rome IV diagnostic criteria for OIC
  • Recent initiation of opioid treatment or a dose increase
  • AND ≥ 2 of the characteristic clinical features of functional constipation:
    • Passage of spontaneous bowel movement < 3 times/week
    • Passage of hard or lumpy stool (more than 25% of defecations)
    • Sensation of anorectal obstruction/blockage (more than 25% of defecations)
    • Manual aid to evacuate stool necessary (more than 25% of defecations)
    • Straining during attempts to defecate (more than 25% of defecations)
    • Sensation of incomplete evacuation (more than 25% of defecations)
  • Loose stools are rarely present without the use of laxatives
• Consider x-ray of the abdomen to rule out fecal impaction

Treatment ^[19][20]

• Similar to the treatment of primary constipation (see “Treatment” and “Laxatives” above)
• Identify and treat any underlying organic cause.
• Lifestyle and dietary modification
• Evaluate the need for opiate therapy and discontinue/reduce dose if appropriate.
• Medical therapy
  • Laxative therapy
    • Osmotic laxative (e.g., polyethylene glycol or lactulose )
    • and/or stimulant laxative (e.g., senna )
  • Options for laxative-refractory OIC:
    • Peripherally acting μ-opioid receptor antagonists
      • Methylnaltrexone
      • Naldemedine
      • Naloxegol
    • Lubiprostone

Discontinue any additional laxatives when initiating a peripherally acting μ-opioid receptor antagonist.

• By course: acute or chronic
• By etiology
  • Primary constipation (functional constipation): constipation in the absence of an identifiable medical disorder
  • Secondary constipation: constipation due to a medical disorder or medication ^[4]

History of present illness

• Onset
• Duration
• Frequency of bowel movements
• Urge to defecate
• Straining during defecation
• Feeling of incomplete evacuation (tenesmus)
• Manual disimpaction or self-digitation
• Character of stools

Associated symptoms

• Gastrointestinal
  • Abdominal distention
  • Abdominal pain
  • Melena and/or hematochezia
  • Obstipation
  • Pronounced flatulence
  • Nausea and/or vomiting
• Anorectal
  • Painful defecation
  • Prolapsing mass
• General
  • Clinically significant weight loss/gain
  • Fatigue
  • Appetite
  • Alteration in diet
  • Physical activity

Past medical history, social history, and family history

• Past medical history
• Past surgical history
• Medications (see constipation-inducing medications)
• Menstrual history
• Allergies
• Alcohol
• Recreational drugs
• Travel history
• Family history

General

• General appearance
• Temperature
• Heart rate
• Blood pressure
• Respiratory rate

Cardiopulmonary

• Auscultation of the heart
• Auscultation of the lungs

Abdominal

• Inspection
  • Abdominal distention
  • Visible mass
  • Visible peristalsis
  • Flank fullness
  • Dilated veins over the anterior abdominal wall
  • Previous surgical scar(s)
• Auscultation
• Percussion
• Palpation
• Evaluate for guarding and/or rigidity
• Evaluate for rebound tenderness
• Check for fluid wave
• Visual inspection of the rectum
  • Fissures and skin tags
  • Hemorrhoids
  • Rectocele
• Digital rectal examination
  • Sphincter tone
  • Anal reflex

In patients with constipation, do not forget to examine the inguinal and pelvic region for an obstructed inguinal or femoral hernia!

Neurological examination

• Focal neurological deficits

Skin

• Evaluation for pallor and icterus
• Rash
• Presence of wrinkles
• Hair

Extremities

• Edema

The diagnostic workup should be guided by the pretest probability of the relevant diagnoses. The following list includes some commonly used diagnostic tools that may be helpful when diagnosing or ruling out possible etiologies in a patient with constipation.

Laboratory studies

• CBC with differential
• Serum glucose and HbA1c
• BMP
• Ionized calcium levels
• Serum parathormone levels
• Serum TSH levels
• FOBT
• CRP

Imaging

• X-ray abdomen
• CT abdomen with IV and oral contrast
• Colonoscopy

Advanced diagnostic testing

• Anorectal manometry
• Colon transit times ^[21]
• Balloon expulsion test
• Defecography (barium or MRI)

In patients with no red flag features, laboratory tests and imaging are not routinely recommended.

The differential diagnoses listed here are not exhaustive.

Chronic laxative use may lead to dependency and/or hypokalemia, which can further reduce bowel motility!

Patients taking osmotic laxatives should be instructed to increase their water consumption.