Practical symptom-based evaluation of chronic constipation

The Journal of Family Practice. 2006 July;55(7):580-584

July 1, 2006|The Journal of Family Practice

Alarm features to look for; distinguishing primary from secondary disorder

FAST TRACK

If a patient reports abdominal pain as the key complaint, consider irritable bowel syndrome

In the case of IBS, abdominal pain is the primary symptom and, by definition, is associated with a change in stool frequency or form. With chronic constipation, however, abdominal pain is not necessarily the primary symptom and is not always related to changes in bowel habits.¹

What symptom duration tells you. Symptom duration can aid in determining whether constipation is occasional or chronic, which may influence the treatment course you recommend. In the absence of clear-cut guidelines differentiating these subcategories, the distinction is often arbitrary: constipation is considered acute/occasional if it lasts less than 3 months and chronic if it lasts 3 months or more.⁴

TABLE 2
Causes of secondary constipation^6-11

MAIN CAUSES	SUGGESTIVE SIGNS AND SYMPTOMS
Medical conditions
GI tract conditions Colon cancer Anal fissure Mucosal prolapse Crohn disease of the anorectum Stricture pseudo-obstruction	Abdominal pain, nausea, cramping, vomiting, weight loss, melena, rectal bleeding, rectal pain, fever, blood in stool
Endocrine disorders Hypothyroidism Hypercalcemia Hyperparathyroidism Diabetes	Reduced body hair, skin dryness, fixed edema, weight gain, urinary frequency, and urgency
Neurologic disorders Hirschsprung disease Autonomic neuropathy Spinal cord injury Multiple sclerosis Parkinson disease	Focal deficits, delayed relaxation phase of the deep tendon reflex, absence of a rectoanal inhibitory reflex, cogwheel rigidity
Systemic condition Scleroderma	Numbness, pain, or color changes in fingers, toes, cheeks, nose, and ears; stiffness or pain in joints; digestive problems; sores over joints; puffy hands and feet, particularly in the morning
Psychological disorders Anxiety Depression Somatization Eating disorders	Signs of depression (eg, flat affect, poor eye contact), history of abuse
Postsurgical complications Abdominal-pelvic Colonic Anorectal	Surgical scars
Female reproduction–related issues Pregnancy Vaginal delivery Ovarian cancer Menstrual cycle–associated changes	Pelvic floor dyssynergia, stress incontinence
Medications
Aluminum-containing antacids, antispasmodics, antidepressants, diuretics, anticonvulsants, pain medications (especially narcotics), and calcium-channel blockers	Prescription and over-the-counter medication use
Lifestyle habits
Inadequate dietary fiber consumption, insufficient fluid intake, inactivity, ignoring urge to defecate	Evidence of poor dietary habits and low level of physical activity

TABLE 3
Select alarm features suggesting dire underlying causes^4,7

HISTORY Unintended weight loss >10 lb Severe, long-term diarrhea or constipation Rectal bleeding (overt or covert) Onset in older patient (>50 years old) Relevant family history of inflammatory bowel disease or colorectal cancer Personal history of colonic neoplasia History of travel to locations with endemic parasitic disease Recent antibiotic use
PHYSICAL EXAMINATION Relevant abnormalities (eg, arthritis, skin findings, abdominal mass, lymphadenopathy)
LABORATORY RESULTS Anemia Leukocytosis High erythrocyte sedimentation rate Abnormal chemistry Abnormal thyroid-stimulating hormone levels

When are diagnostic tests warranted?

The choice of diagnostic tests and the timing of those tests is a judgment call in each case, ultimately based on your experience and clinical assessment. There are no universally accepted standards, but recently published evidence-based recommendations by the ACG Task Force on Chronic Constipation serve as a useful guide.

Per these recommendations, for patients with chronic constipation who do not exhibit alarm features, evidence is insufficient to recommend routine diagnostic testing (eg, colonoscopy, flexible sigmoidoscopy, barium enema, serum calcium, thyroid function tests) (ACG grade: C). In the presence of alarm features, however, relevant diagnostic tests are indicated (ACG grade: C).

FAST TRACK

For a patient 50 years or older with no alarm features, the only diagnostic test you need to perform is colon cancer screening

Routine colon cancer screening tests for all patients aged 50 years or older is recommended (ACG grade: C).

In summary, per these guidelines, the routine initial approach to patients with chronic constipation but without alarm features is empiric treatment without diagnostic testing.⁴

Acknowledgments

The author acknowledges the editorial assistance of Meera Nathan, PhD, Maribeth Bogush, PhD, and Sophia Shumyatsky, PharmD in the preparation of this manuscript.

CORRESPONDENCE
Scott D. Bleser, DO, FAAFP, Bellbrook Medical Center, Inc, 4336 State Route 725, Bellbrook, OH 45305-2742. E-mail: scottbleser@woh.rr.com

References

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