Constipation

Notes
  • A constipated patient (according to Rome III criteria for constipation) must have experienced at least 2 of the following symptoms:less than 3 bowel movements per week, straining   lumpy or hard stools; sensation of anorectal obstruction; sensation of incomplete defecation and manual maneuvering required to pass stool.
Symptoms
  • Obstructive lesions; irritable bowel syndrome; diabetes; neurological or endocrine abnormalities such as hypothyroidism; physical inactivity; inadequate water or food (and particularly fibres); medicines such as opioids, sedatives and iron supplements; laxative abuse, spinal injury; amyloidosis and other autoimmune diseases.
Diagnosis
  • Clinical review
  • Thyroid function tests (TFTs)
  • Abdominal X-rays
  • Barium enema
  • Colonoscopy
  • FBC
  • Serum glucose.
Differential
  • Abdominal Hernias
  • Anxiety Disorders
  • Appendicitis
  • Colon Cancer
  • Use of medicines such calcium blockers, opiates, iron supplements, and aluminium and calcium-based antacids.
  • Colonic Obstruction
  • Crohn’s Disease
  • Depression
  • Large-Bowel Obstruction
  • Peritonitis
  • Pregnancy
  • Abdominal Sepsis
  • Uremia
  • Milk-alkali syndrome
  • Diabetes Mellitus
  • Diverticulitis
  • Hypopituitarism
  • Hypothyroidism
  • Ileus Intestinal Motility Disorders
  • Irritable Bowel Syndrome
  • Large-Bowel Obstruction
  • Genetics of Neurofibromatosis Type 1 and Type 2
  • Hirschsprung Disease (Peadiatric)
  • Hypercalcemia
  • Pediatric Hypokalemia
  • Imperforate Anus (Peadiatric)
  • Peritonitis
  • Abdominal Sepsis
  • Toxic Megacolon
Prevention
  • Treatment of underlying illness
  • Inadequate water or food (and particularly fibres)
  • Good toilet habit such as not ignoring the need defecate and adequate time in the toilet.
  • Exercises
Management
  • Bisacodyl 5mg tablets; oral dose of 5-10mg nocte; can be increased to 15-20mg.
    • Other treatment / prevention measures
      • For children: pawpaw or bananas to increase fibre in the diet.
      • Adequate of water and fibre diet
      • Disimpaction manually (with or without anal retractor); enemas.
      • Training a child to use the toilet at a predetermined intervals.
    • Bisacodyl in children: 5mg by rectum.
    • Senna (senakot): 2-4 tabs at bedtime. Start with a low dose. Child over 6 years: half adult dose.
    • Sulfolax (docusate): 5-10 drops in one dose/day. Children: 2-5 drops in one dose/day before going to bed.
    • Phosphate enema: Adult: 1 pack. Children: 1/9 - 1/2 content of the enema.
    • Glycerin suppositories: infant - 1g; child - 2g; adult - 4g.
    • Lactulose: 15mL BD [adjusted accordingly]. Children under 1 year 2.5mL, 1-5 years 5ml, 6-12 years: BD [gradually reduced].
    • Magnesium sulphate: 5-10g in a glass of water preferably before breakfast.
    • Polyethylene Glycol & Electrolytes: 17gm in 120-240mLwater PO OD for ≤1 wk

 

Other considerations

  • In infants, delayed passage of meconium for a period between 24 to 48hrs after birth raises suspicion of Hirschsprung disease and other structural disorders e.g. anorectal malformations, spinal cord abnormalities, cystic fibrosis, and metabolic disorders (hypothyroidism, hypercalcemia and hyperkalemia etc.).
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