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Symptoms and Signs – Differential Diagnosis of Constipation
Constipation
Constipation is defined as small, infrequent, or difficult bowel movements. Given the variability in frequency and individuality of regular bowel movements, constipation is a relative condition that needs to be assessed in connection to the patient's normal elimination pattern. Constipation can be relatively insignificant or, in rare cases, an indication of a potentially fatal condition like an abrupt intestinal blockage. If left untreated, constipation can result in headache, anorexia, and abdominal discomfort, therefore negatively impacting the patient's lifestyle and overall well-being.
Constipation often arises when the desire to urinate is repressed and the muscles involved in bowel motions stay tense. Given that the autonomic nervous system regulates bowel movements through the detection of rectal distension from fecal contents and the activation of the external sphincter, any effect on this system can lead to bowel disorder.
Historical Background and Physical Assessment
Request that the patient provide a detailed account of the frequency of his bowel movements, as well as the dimensions and texture of his feces. With what duration has he experienced constipation? Acute constipation often arises from a physiological etiology, such as an anal or rectal inflammatory condition. Newly developed constipation in a patient over 45 years old may indicate the presence of colorectal cancer at an early stage. In contrast, chronic constipation usually can be attributed to a functional factor and may be associated with stress.
Is the patient experiencing pain only associated with constipation? If such is the case, when did he initially perceive the discomfort, and what is its precise spatial location? Distension and cramping abdominal pain indicate obstipation, which is severe and ongoing constipation caused by blockage in the intestinal tract. Indicate to the patient if feces exacerbates or alleviates the discomfort. Defecation often exacerbates pain, but in cases with conditions like irritable bowel syndrome, it can in fact alleviate it.
Seek the patient's description of a standard daily diet, including an estimation of his daily consumption of fiber and fluids. Request information regarding alterations in dietary patterns, usage of drugs or alcohol, and level of physical exercise. Has he encountered recent symptoms of mental distress? To what extent has constipation impacted his familial relationships or social interactions? Ask about his employment and exercise regimen as well. Engaging in a sedentary or demanding occupation can exacerbate constipation.
Determine if the patient has a diagnosed medical history of gastrointestinal, rectoanal, neurological, or metabolic diseases; undergone abdominal surgery; or received radiation therapy. Next, inquire about the pharmaceuticals he is currently using, including opioids and non-prescription remedies like laxatives, mineral oil, stool softeners, and enemas.
Examine the abdomen for any signs of distension or scars resulting from prior surgical procedures. Proceed to auscultate for bowel sounds and analyze their motility. Percuss each of the four
Identify the quadrants and carefully examine for abdominal discomfort, a detectable mass, and hepatomegaly. Next, inspect the patient's rectal region. Protrude his buttocks to reveal the anus, and examine for signs of inflammation, lesions, scars, fissures, and external hemorrhoids. Employ a single-use glove and lubricant to manually examine the anal sphincter for any signs of looseness or tightness. Furthermore, examine for rectal lumps and fecal impaction by palpation. Finally, collect a feces sample and conduct occult blood testing on it.
When evaluating the patient, it is important to note that constipation can arise from various potentially fatal diseases, including acute intestinal blockage and mesenteric artery ischemia. However, it does not reliably indicate the presence of these problems.
Medical Causes
Anal fissure
A fissure or rupture in the mucosal lining of the anal wall can lead to sudden constipation, sometimes caused by the patient's apprehension of the intense tearing or burning sensation linked to defecation. A few drips of blood may be visible staining toilet tissue or his undergarments.
Anorectal abscess
Anorectal abscess is characterized by constipation accompanied by intense, pulsating, localised pain and tenderness at the site of the abscess. In addition, the patient may exhibit localized inflammation, edema, and purulent discharge, and may report to have fever and malaise.
Cirrhosis
During the initial phases of cirrhosis, the patient reports constipation, accompanied by nausea and vomiting, as well as a persistent pain in the right upper quadrant. Additional initial observations include dyspepsia, loss of appetite, exhaustion, malaise, intestinal distension, enlarged liver, and potentially, enlarged spleen and diarrhea.
Diabetic neuropathy
Diabetic neuropathy results in sporadic episodes of constipation or ulceration. Additional indications and manifestations for this condition include dysphagia, orthostatic hypotension, syncope, and painless bladder distension accompanied with overflow incontinence. Additionally, a male patient may encounter erectile dysfunction and retrograde ejaculation.
Diverticulitis
Constipation or diarrhea accompanied by left lower quadrant pain and tenderness, and perhaps a palpable, tender, firm, fixed abdominal mass, are symptoms of diverticulitis. Possible symptoms experienced by the patient include minor nausea, flatulence, or a low-grade fever.
Haemorrhoids
Patients with thrombosed hemorrhoids experience constipation as they attempt to avoid the intense discomfort associated with defecation. Defecation may result in bleeding of the hemorrhoids.
Hepatic porphyria
In hepatic porphyria, a rare genetic pathology that impacts the liver, abdominal pain, which can be intense, occurs before constipation.
production of heme
The patient may in addition have symptoms of nausea, vomiting, muscle weakness, back, arm, and leg pain, crimson urine, palpitations, hallucinations, and seizures.
Hypercalcemia
In cases of hypercalcemia, constipation often coexists with anorexia, nausea, vomiting, abnormal urination, and excessive thirst. In addition, the patient may exhibit arrhythmias, osteoarthritis, muscular weakness and atrophy, diminished deeper tendon reflexes, and alterations in personality.
Hypothyroidism
Among people with hypothyroidism, constipation manifests early and gradually, along with fatigue, sensitivity to cold, anorexia accompanied by weight gain, menorrhagia in women, reduced memory, hearing loss, muscle cramps, and paresthesia.
Intestinal obstruction
The manifestation and initiation of constipation related to an intestinal blockage differ based on the specific site and magnitude of the blockage. Under conditions of partial obstruction, constipation may alternate with the passage of liquid stools. Complete occlusion can lead to the occurrence of obstipation. Although constipation might be the first indication of partial colon blockage, it typically manifests later if the blockage is located closer to the origin. Common accompanying symptoms include occurrences of colicky abdomen discomfort, abdominal distension, nausea, or vomiting. In addition, the patient may have hyperactive bowel sounds, observable peristaltic waves, a detectable abdominal mass, and abdominal discomfort.
Irritable bowel syndrome (IBS)
Irritable Bowel Syndrome (IBS) often results in recurrent constipation, however individual patients may experience sporadic, watery diarrhea or report alternating episodes of constipation and diarrhea. Stress and specific meals can induce nausea and stomach distension and pain, although the act of defecating often alleviates these physiological manifestations. Patients commonly experience a strong urge to urinate and subjective sensations of incomplete evacuation. As a general rule, the stools are scybalous and consist of visible mucus.
Mesenteric artery ischemia
Mesenteric artery ischemia is a life- threatening disorder that produces sudden constipation with failure to expel stool or flatus. Early on, the abdomen is pliable and painless, but quickly intense abdominal pain, sensitivity, vomiting, and loss of appetite develop. Subsequently, the patient may experience abdominal guarding, rigidity, and distention; increased heart rate; brief loss of consciousness; rapid breathing; a fever; and indications of shock, such as cold, damp skin and low blood pressure. An audible bruit may be detected.
Spinal cord lesion
Constipation, along with urine retention, sexual dysfunction, discomfort, and potentially motor weakness, paralysis, or sensory impairment below the lesion level, may present as symptoms of a spinal cord injury.
Additional Factors
Diagnostic examinations
The retention of barium administered during some gastrointestinal investigations can lead to constipation.
Substance abuse. Constipation is a frequent side effect experienced by patients who are prescribed opioid analgesics or other medications, such as Vinca alkaloids, calcium channel blockers, antacids containing aluminum or calcium, anticholinergics, and medicines with anticholinergic properties (trcyclic antidepressants). In addition, patients may have constipation due to the over use of laxatives or enemas.
Surgical procedures and radiation therapy.
Constipation can occur as a consequence of rectoanal surgery, which can potentially damage nerves, and abdominal irradiation, which can lead to intestinal stricture.
Special Considerations
Arrange the patient for diagnostic procedures including proctosigmoidoscopy, colonoscopy, barium enema, plain abdomen films, and an upper gastrointestinal series as recommended. While the patient is confined to bed, it is important to regularly reposition him and assist him in carrying out any active or passive activities. Instruct the patient in abdominal toning activities to address weakly abdominal muscles and relaxing strategies to alleviate tension associated with constipation.
Individualised Counselling
Promote abstinence from abdominal straining, laxatives, and enemas. Articulate the function of nutrition and hydration. Discourse and motivate the patient to engage in physical activity, specifically focusing on belly toning activities. Provide him with instruction in relaxation techniques.
Guidelines for Pediatrics
The elevated concentration of casein and calcium in bovine milk can result in the formation of firm feces and potential constipation in newborns who are fed with bottles. Additional etiologies of constipation in neonates encompass insufficient fluid consumption, Hirschsprung's disease, and anal fissures. The primary causes of constipation in older children are insufficient fiber consumption and excessive milk intake. Other contributing factors include intestinal spasm, mechanical obstruction, hypothyroidism, an unwillingness to stop playing for bathroom breaks, and the absence of privacy in certain school bathrooms.
Guidelines for Geriatrics
Substantial structural problems are often the underlying cause of acute constipation in elderly people. Nevertheless, chronic constipation is mostly attributed to long-term bowel and dietary patterns, as well as the use of laxatives.
Constipation
Constipation is defined as small, infrequent, or difficult bowel movements. Given the variability in frequency and individuality of regular bowel movements, constipation is a relative condition that needs to be assessed in connection to the patient's normal elimination pattern. Constipation can be relatively insignificant or, in rare cases, an indication of a potentially fatal condition like an abrupt intestinal blockage. If left untreated, constipation can result in headache, anorexia, and abdominal discomfort, therefore negatively impacting the patient's lifestyle and overall well-being.
Constipation often arises when the desire to urinate is repressed and the muscles involved in bowel motions stay tense. Given that the autonomic nervous system regulates bowel movements through the detection of rectal distension from fecal contents and the activation of the external sphincter, any effect on this system can lead to bowel disorder.
Historical Background and Physical Assessment
Request that the patient provide a detailed account of the frequency of his bowel movements, as well as the dimensions and texture of his feces. With what duration has he experienced constipation? Acute constipation often arises from a physiological etiology, such as an anal or rectal inflammatory condition. Newly developed constipation in a patient over 45 years old may indicate the presence of colorectal cancer at an early stage. In contrast, chronic constipation usually can be attributed to a functional factor and may be associated with stress.
Is the patient experiencing pain only associated with constipation? If such is the case, when did he initially perceive the discomfort, and what is its precise spatial location? Distension and cramping abdominal pain indicate obstipation, which is severe and ongoing constipation caused by blockage in the intestinal tract. Indicate to the patient if feces exacerbates or alleviates the discomfort. Defecation often exacerbates pain, but in cases with conditions like irritable bowel syndrome, it can in fact alleviate it.
Seek the patient's description of a standard daily diet, including an estimation of his daily consumption of fiber and fluids. Request information regarding alterations in dietary patterns, usage of drugs or alcohol, and level of physical exercise. Has he encountered recent symptoms of mental distress? To what extent has constipation impacted his familial relationships or social interactions? Ask about his employment and exercise regimen as well. Engaging in a sedentary or demanding occupation can exacerbate constipation.
Determine if the patient has a diagnosed medical history of gastrointestinal, rectoanal, neurological, or metabolic diseases; undergone abdominal surgery; or received radiation therapy. Next, inquire about the pharmaceuticals he is currently using, including opioids and non-prescription remedies like laxatives, mineral oil, stool softeners, and enemas.
Examine the abdomen for any signs of distension or scars resulting from prior surgical procedures. Proceed to auscultate for bowel sounds and analyze their motility. Percuss each of the four
Identify the quadrants and carefully examine for abdominal discomfort, a detectable mass, and hepatomegaly. Next, inspect the patient's rectal region. Protrude his buttocks to reveal the anus, and examine for signs of inflammation, lesions, scars, fissures, and external hemorrhoids. Employ a single-use glove and lubricant to manually examine the anal sphincter for any signs of looseness or tightness. Furthermore, examine for rectal lumps and fecal impaction by palpation. Finally, collect a feces sample and conduct occult blood testing on it.
When evaluating the patient, it is important to note that constipation can arise from various potentially fatal diseases, including acute intestinal blockage and mesenteric artery ischemia. However, it does not reliably indicate the presence of these problems.
Medical Causes
Anal fissure
A fissure or rupture in the mucosal lining of the anal wall can lead to sudden constipation, sometimes caused by the patient's apprehension of the intense tearing or burning sensation linked to defecation. A few drips of blood may be visible staining toilet tissue or his undergarments.
Anorectal abscess
Anorectal abscess is characterized by constipation accompanied by intense, pulsating, localised pain and tenderness at the site of the abscess. In addition, the patient may exhibit localized inflammation, edema, and purulent discharge, and may report to have fever and malaise.
Cirrhosis
During the initial phases of cirrhosis, the patient reports constipation, accompanied by nausea and vomiting, as well as a persistent pain in the right upper quadrant. Additional initial observations include dyspepsia, loss of appetite, exhaustion, malaise, intestinal distension, enlarged liver, and potentially, enlarged spleen and diarrhea.
Diabetic neuropathy
Diabetic neuropathy results in sporadic episodes of constipation or ulceration. Additional indications and manifestations for this condition include dysphagia, orthostatic hypotension, syncope, and painless bladder distension accompanied with overflow incontinence. Additionally, a male patient may encounter erectile dysfunction and retrograde ejaculation.
Diverticulitis
Constipation or diarrhea accompanied by left lower quadrant pain and tenderness, and perhaps a palpable, tender, firm, fixed abdominal mass, are symptoms of diverticulitis. Possible symptoms experienced by the patient include minor nausea, flatulence, or a low-grade fever.
Haemorrhoids
Patients with thrombosed hemorrhoids experience constipation as they attempt to avoid the intense discomfort associated with defecation. Defecation may result in bleeding of the hemorrhoids.
Hepatic porphyria
In hepatic porphyria, a rare genetic pathology that impacts the liver, abdominal pain, which can be intense, occurs before constipation.
production of heme
The patient may in addition have symptoms of nausea, vomiting, muscle weakness, back, arm, and leg pain, crimson urine, palpitations, hallucinations, and seizures.
Hypercalcemia
In cases of hypercalcemia, constipation often coexists with anorexia, nausea, vomiting, abnormal urination, and excessive thirst. In addition, the patient may exhibit arrhythmias, osteoarthritis, muscular weakness and atrophy, diminished deeper tendon reflexes, and alterations in personality.
Hypothyroidism
Among people with hypothyroidism, constipation manifests early and gradually, along with fatigue, sensitivity to cold, anorexia accompanied by weight gain, menorrhagia in women, reduced memory, hearing loss, muscle cramps, and paresthesia.
Intestinal obstruction
The manifestation and initiation of constipation related to an intestinal blockage differ based on the specific site and magnitude of the blockage. Under conditions of partial obstruction, constipation may alternate with the passage of liquid stools. Complete occlusion can lead to the occurrence of obstipation. Although constipation might be the first indication of partial colon blockage, it typically manifests later if the blockage is located closer to the origin. Common accompanying symptoms include occurrences of colicky abdomen discomfort, abdominal distension, nausea, or vomiting. In addition, the patient may have hyperactive bowel sounds, observable peristaltic waves, a detectable abdominal mass, and abdominal discomfort.
Irritable bowel syndrome (IBS)
Irritable Bowel Syndrome (IBS) often results in recurrent constipation, however individual patients may experience sporadic, watery diarrhea or report alternating episodes of constipation and diarrhea. Stress and specific meals can induce nausea and stomach distension and pain, although the act of defecating often alleviates these physiological manifestations. Patients commonly experience a strong urge to urinate and subjective sensations of incomplete evacuation. As a general rule, the stools are scybalous and consist of visible mucus.
Mesenteric artery ischemia
Mesenteric artery ischemia is a life- threatening disorder that produces sudden constipation with failure to expel stool or flatus. Early on, the abdomen is pliable and painless, but quickly intense abdominal pain, sensitivity, vomiting, and loss of appetite develop. Subsequently, the patient may experience abdominal guarding, rigidity, and distention; increased heart rate; brief loss of consciousness; rapid breathing; a fever; and indications of shock, such as cold, damp skin and low blood pressure. An audible bruit may be detected.
Spinal cord lesion
Constipation, along with urine retention, sexual dysfunction, discomfort, and potentially motor weakness, paralysis, or sensory impairment below the lesion level, may present as symptoms of a spinal cord injury.
Additional Factors
Diagnostic examinations
The retention of barium administered during some gastrointestinal investigations can lead to constipation.
Substance abuse. Constipation is a frequent side effect experienced by patients who are prescribed opioid analgesics or other medications, such as Vinca alkaloids, calcium channel blockers, antacids containing aluminum or calcium, anticholinergics, and medicines with anticholinergic properties (trcyclic antidepressants). In addition, patients may have constipation due to the over use of laxatives or enemas.
Surgical procedures and radiation therapy.
Constipation can occur as a consequence of rectoanal surgery, which can potentially damage nerves, and abdominal irradiation, which can lead to intestinal stricture.
Special Considerations
Arrange the patient for diagnostic procedures including proctosigmoidoscopy, colonoscopy, barium enema, plain abdomen films, and an upper gastrointestinal series as recommended. While the patient is confined to bed, it is important to regularly reposition him and assist him in carrying out any active or passive activities. Instruct the patient in abdominal toning activities to address weakly abdominal muscles and relaxing strategies to alleviate tension associated with constipation.
Individualised Counselling
Promote abstinence from abdominal straining, laxatives, and enemas. Articulate the function of nutrition and hydration. Discourse and motivate the patient to engage in physical activity, specifically focusing on belly toning activities. Provide him with instruction in relaxation techniques.
Guidelines for Pediatrics
The elevated concentration of casein and calcium in bovine milk can result in the formation of firm feces and potential constipation in newborns who are fed with bottles. Additional etiologies of constipation in neonates encompass insufficient fluid consumption, Hirschsprung's disease, and anal fissures. The primary causes of constipation in older children are insufficient fiber consumption and excessive milk intake. Other contributing factors include intestinal spasm, mechanical obstruction, hypothyroidism, an unwillingness to stop playing for bathroom breaks, and the absence of privacy in certain school bathrooms.
Guidelines for Geriatrics
Substantial structural problems are often the underlying cause of acute constipation in elderly people. Nevertheless, chronic constipation is mostly attributed to long-term bowel and dietary patterns, as well as the use of laxatives.
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