03.13 Constipation
Clerking
PC: Constipation
HPC:
Duration
Description of stools – use Bristol stool chart
How often do they normally pass stools? What type of stools?
Mixed with blood?
Feeling of incomplete excretion?
Able to pass flatus?
Other GI smx:
- Loose stools (alternating?) ± incontinence?
- Abdominal pain
- Bloating
- Nausea and vomiting
- Dysphagia?
Red flags:
- Wt loss
- Fever
- Night sweats
PMH:
* ask specifically about past surgical Hx
DHx:
* also ask about OTC products ± if they have tried any laxatives
FHx:
* ask about FHx of GI conditions
SHx:
Baseline: iADL? Bedbound/carehome - etc
Smoking
Alcohol
Diet
Obs:
Bloods:
Imaging:
O/E
Alert, oriented, answering questions
DRE - chaperoned by
Imp:
Plan
Further Ix depending on history
Digital rectal exam – usually done unless in children
Bloods – routine + bone profile, TFTs
Imaging – abdo XR (?faecal loading, bowel obstruction, perforation) ± CTAP (usually requested if concerns about bowel obstruction)
DDx using surgical sieve
Vascular
Infectious
Trauma / surgical
Previous surgery can cause adhesions/strictures leading to bowel obstruction – see 03.06
Diverticular disease
Autoimmune
Metabolic
Hypercalcaemia (remember bones, stones, moans, groans)
Hypothyroidism
Cystic fibrosis
Dehydration
Iatrogenic – think medications
Opioids!!!! Esp codeine – don’t prescribe codeine in older people without laxatives
Anticholinergics (eg amitriptyline, chlorpheniramine, oxybutynin, tolteridine) – see here for longer list (scroll down)
Antidepressants & antipsychotics can also be associated with constipation as well (eg amitriptyline, olanzapine)
Iron and calcium supplements
Note also iron can produce “dark tarry stools” that may be mistaken for melaena
Antacids
NSAIDs (eg ibuprofen) – not common
Neoplasm / neurological
Bowel Ca – CIBH + iron deficiency anaemia or other concerning signs in ≥40yo = investigate for bowel Ca
Prostate Ca – can cause external compression
Neurological: dementia, MS, Parkinson’s
Congenital
Hirshsprung
CF
Degenerative
Environmental
Psychological
Irritable bowel syndrome
Pregnancy
Constipation is not uncommon in pregnancy
Management
Bowel obstruction – 03.06
Abdo XR in the first instance
Refer to surgeons
Drip and suck – Ryles tube + IV fluids
Neoplasm
Diverticular disease – 03.10
Usually managed by increasing fibre intake (eg isphagula husk) ± laxatives
Hypercalcaemia (06.07)
IV fluids
Remove offending drugs if present
Hyothyroidism (06.01)
Laxatives
Refer to endocrine – may need starting thyroid replacement
Irritable bowel syndrome – 03.10
Antispasmodics eg hyoscine
Laxatives, eg macrogols
Iatrogenic – remove offending drugs
