Causes of Constipation

1. Causes of Constipation

2. Main Point Constipation is a SYMPTOM Constipation is not a diagnosis

3. Definition • Persistent, difficult, infrequent or seemingly incomplete defaecation • Normal frequency ? - variable • 3 times per day to once per 3 days • Normal consistency ? • Excessive straining, hard stools, lower abdominal fullness, sense of incomplete evacuation • Subjective • Psychosocial factors

4. Causes How many can you think of ??? Subdivide into Recent and Chronic

5. Recent Constipation • A recent and persistent change in bowel habit needs to be investigated unless there is an obvious cause (new drug, illness etc) • Especially if • Older person • Excessive straining, feeling of incomplete emptying • Anaemia / rectal bleeding

6. Recent Constipation • Colonic Obstruction • Neoplasm • Stricture • Ischaemia • Diverticular • Inflammatory

7. Recent Constipation • Anal Sphincter Spasm • Anal fissure • Painful haemorrhoids • Medications • Suggestions? • Situational • Illness, bedfast, immobile, hospitalisation • Terminal reservoir syndrome / faecal impaction

8. Chronic Constipation Bowel • Irritable bowel syndrome • Constipation predominant, alternating • Slow transit • Rectal evacuation disorders • Pelvic floor dysfunction • Anismus • Rectal mucosal prolapse • Rectocoele

9. Irritable Bowel Syndrome • Chronic abdominal pain • Altered bowel habit • No apparent cause • Other symptoms • GI: Dyspepsia, nausea, bloating, excess gas, pain • Urinary sx, fibromyalgia sx, sexual dysfunction • All age groups; F:M = 2:1

10. Chronic Constipation Bowel • Irritable bowel syndrome • Constipation predominant, alternating • Slow transit • Rectal evacuation disorders • Pelvic floor dysfunction • Anismus • Rectal mucosal prolapse • Rectocoele

11. Chronic Constipation Neurological - Central • Parkinson’s Disease • Multiple Sclerosis • Spinal cord injury Neurological – Peripheral • Diabetes Mellitis • Autonomic neuropathy

12. Chronic Constipation Endocrine • Hypothyroidism / Panhypopituitism • Hypercalcaemia • Hypokalaemia • Pregnancy (but not in Older People)

13. Chronic Constipation Psychiatric • Depression • Eating disorders, anorexia nervosa Muscle • Systemic sclerosis (Scleroderma) • Myotonic dystrophy

14. Medications • Analgesics • Paracetamol, Codeine, Opioids • Anticholinergics • Antidepressants (Amitriptylline) • Antipsychotics (Chlorpromazine) • Parkinson’s disease drugs • Oxybutinin • Antihistamines • Antispasmodics

15. Medications • Cations • Aluminium, Iron, Bismuth • Antihypertensives • Calcium channel blockers (Verpamil) • Cancer Drugs • Chronic laxative abuse

16. Older People • Diet – • Reduced caloric intake • Reduced fibre and fluid? • Poor dentition • Reduced mobility / exercise • Less perception of rectal fullness • Chronic illness: less mobile / more bed rest • Dementia

17. “Alarm” Features • Weight loss (> 5 kg) • Rectal bleeding / Anaemia • Electrolyte abnormalities • Raised inflammatory markers • Family Hx: • Carcinoma colon • Inflammatory Bowel Disease

18. Summary • No cause in >90% patients who complain of chronic constipation • Severe intractable constipation in <5% • Need more detailed assessment • Constipation is a symptom not a diagnosis • Keep alert for “Alarm Features”