HISIORY As with diarrhea, part of the challenge of treating patients with the complaint of constipation is determining whether they actually are constipated. Ihe easiest, most practical definition of constipation is the following: the presence of hard stools that are difficult to pass. Some patients become bowel fixated and feel they are constipated if they do not have a daily bowel movement. Ihey are not.
Once a physician determines that a patient truly is constipated, the physician must attempt to determine the cause. Ihe differential diagnosis is broad ( Iab!e...Z9.-3). Determining the onset of the constipation helps narrow the differential diagnosis. Acute constipation represents intestinal obstruction until proven otherwise. Iumors, strictures, and volvuli can all present as acute constipation. Physicians often mistake subacute for chronic constipation. Ihe important distinction here is to determine exactly when bowel habits changed. Generally, acute and subacute conditions have the same differential diagnosis. Chronic constipation, that is, a lifelong or persistent habit, is usually less ominous and, if uncomplicated, can often be managed on an outpatient basis. Ihe presence or absence of associated symptoms may help guide decision making. Vomiting rarely accompanies benign constipation. Inability to pass flatus also raises concern about obstruction. A history of gradually diminishing stool caliber may suggest colon cancer, especially if accompanied by weight loss. Ihe physician should ask the patient about recent changes in dietary fiber or fluid intake. What other medical problems does the patient have? Is there a history of hypothyroidism or diabetes? An antecedent history of diverticulitis may point toward inflammatory stricture. A history of nephrolithiasis could suggest hyperparathyroidism as a cause for constipation. A quick review of the patient's medication list may also point to the culprit.
PHYSICAL EXAMINAIION Ihe physical examination should concentrate on ruling out organic causes of constipation. First and foremost, intestinal obstruction must be ruled out. The patient should be examined carefully for the presence or absence of hernias and abdominal or pelvic masses. Rectal and pelvic examinations are necessary. In addition to detecting the presence or absence of an obstructing rectal mass, rectal examination also enables the physician to ascertain whether there is fecal impaction. Anal fissures are also detected during the rectal examination. In addition, rectal examination allows the physician to determine whether the stools are bloody. Guaiac-positive stools can be seen in both functional constipation and constipation resulting from colon cancer. With constipation resulting in fecal impaction, rectal mucosa often ulcerates, forming stercoral ulcers on the rectal walls, which yield guaiac-positive stools. With constipation caused by tumor, stools are also often guaiac positive. Constipation and new ascites in postmenopausal women should prompt evaluation for ovarian or uterine carcinoma. Signs of hypothyroidism may also be evident during the physical examination.
The evaluation of a constipated patient depends on the clinician's level of concern for organic causes of constipation. Patients with a long-standing history of constipation often require little, if any, data acquisition, provided the history and physical examination do not point toward an organic process. An upright chest film and abdominal flat and erect films should be obtained in patients who are at risk for intestinal obstruction: patients with prior abdominal surgery, associated vomiting, significant abdominal distention, abdominal pain, and an acute or subacute history of constipation. In addition to assessing the presence or absence of intestinal obstruction, abdominal films allow the physician to assess stool burden. In patients in whom an organic cause for constipation is suspected, a complete blood count should be obtained to screen for anemia. In addition, thyroid function tests may be helpful with patients in whom the physician suspects hypothyroidism. Electrolyte abnormalities, specifically hypokalemia and hypercalcemia, can be associated with constipation and are worth checking with patients suspected of having an organic cause.
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Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.