Doctors Revision

Gastrointestinal & Hepatic System

Constipation

A condition characterized by infrequent bowel movements (<3 per week), difficulty passing stools (straining, hard/lumpy stools, sensation of incomplete evacuation or blockage). Can be acute or chronic.

Also known as: Hard Stools

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Referral and warning signs

When to refer

Referral to specialist (Gastroenterology/Colorectal Surgery) if: ALARM FEATURES present. Severe constipation refractory to standard lifestyle and laxative measures. Suspected underlying motility disorder or pelvic floor dysfunction requiring specialized testing. Suspected secondary cause requiring specific management (e.g., malignancy, severe hypothyroidism).

Red flags

  • Rectal bleeding
  • Unintentional weight loss
  • Iron deficiency anaemia
  • Positive FOBT/FIT
  • New onset constipation in older adult (>45-50 yrs) without prior screening
  • Significant change in bowel habit
  • Family history of colorectal cancer or inflammatory bowel disease
  • Severe, persistent abdominal pain or distension
  • Signs of obstruction

Signs and symptoms

  • Infrequent bowel movements (<3/week)
  • Hard, lumpy stools (Bristol Stool Form Scale type 1-2)
  • Straining during defecation
  • Sensation of incomplete evacuation
  • Sensation of anorectal obstruction/blockage
  • Manual manoeuvres needed to facilitate defecation (e.g., digital evacuation)
  • Abdominal discomfort, bloating, cramping

Risk factors

  • Dietary: Low fibre intake, inadequate fluid intake.
  • Lifestyle: Lack of physical activity, ignoring the urge to defecate.
  • Medications: Opioids, anticholinergics, antidepressants (TCAs), antipsychotics, calcium channel blockers, iron supplements, aluminium-containing antacids, diuretics.
  • Medical Conditions:
  • - Endocrine/Metabolic: Hypothyroidism, Diabetes mellitus, Hypercalcemia, Hypokalaemia.
  • - Neurological: Parkinson's disease, Multiple sclerosis, Spinal cord injury, Stroke, Autonomic neuropathy.
  • - Gastrointestinal: Irritable Bowel Syndrome (IBS-C), Colonic inertia, Pelvic floor dysfunction (dyssynergic defecation), Anal fissure, Haemorrhoids, Strictures, Colorectal cancer.
  • Pregnancy.
  • Older age.
  • Psychological factors (depression, anxiety).

Diagnosis

Clinical assessment

Diagnosis based on patient's symptoms meeting criteria (e.g., Rome IV criteria for functional constipation). History crucial for duration, stool characteristics, straining, associated symptoms, diet, medications, medical history. Physical exam includes abdominal palpation (masses, tenderness), digital rectal examination (assess sphincter tone, check for impaction, mass, stricture, pelvic floor descent). Identify ALARM FEATURES requiring further investigation.

Investigations

  • Usually not required for simple constipation if no alarm features.
  • Indicated if ALARM FEATURES present or failure of initial management:
  • - Blood tests: CBC (anaemia), TSH (hypothyroidism), Calcium, Electrolytes, Glucose.
  • - Faecal Occult Blood Test (FOBT) / Faecal Immunochemical Test (FIT): Screen for colorectal cancer.
  • - Colonoscopy: If alarm features (rectal bleeding, weight loss, iron deficiency anaemia, change in bowel habit >45-50yrs, family history CRC) or positive FOBT/FIT.
  • - Abdominal X-ray: Can show faecal loading/impaction, obstruction.
  • - Colonic Transit Study / Anorectal Manometry / Defecography: Specialist tests for refractory constipation to assess motility/pelvic floor function.

Diagnostic criteria

Based on symptom criteria (e.g., Rome IV) for chronic constipation, after excluding secondary causes and alarm features.

Management

Non-pharmacological management

  • Lifestyle and Dietary Modifications (First-line):
  • - Increase dietary fibre (fruits, vegetables, whole grains, psyllium husk). Aim 20-35g/day. Introduce gradually to avoid bloating.
  • - Increase fluid intake (e.g., 1.5-2 L/day).
  • - Regular physical activity.
  • - Bowel Training: Encourage regular toileting time (e.g., after meals), respond promptly to urge to defecate, adequate time/privacy.
  • - Review medications and stop/change causative agents if possible.
  • Manual Disimpaction: If faecal impaction present on rectal exam.

Pharmacological treatment

  • Laxatives (Use stepwise approach if lifestyle changes insufficient):
  • 1. Bulk-forming laxatives: Psyllium, Methylcellulose, Ispaghula husk (require adequate fluid intake).
  • 2. Osmotic laxatives: Lactulose (syrup), Polyethylene glycol (PEG solutions), Magnesium salts (e.g., Milk of Magnesia). Draw water into bowel.
  • 3. Stimulant laxatives: Bisacodyl (oral/suppository), Senna. Stimulate peristalsis. Use short-term usually, risk of dependence/cramping.
  • 4. Stool Softeners: Docusate sodium (limited efficacy for constipation itself).
  • 5. Suppositories/Enemas: Glycerin suppositories, Phosphate enemas (use with caution, esp. elderly/renal impairment). Useful for faecal impaction/rectal emptying.
  • Newer agents (Specialist use for refractory constipation): Lubiprostone, Linaclotide, Prucalopride.

Monitoring

  • Monitor bowel movement frequency and consistency.
  • Assess symptom relief.
  • Monitor for side effects of laxatives (bloating, cramping, electrolyte disturbance).
  • Re-evaluate if symptoms persist or worsen.

Complications

  • Faecal impaction
  • Haemorrhoids
  • Anal fissures
  • Rectal prolapse
  • Overflow diarrhoea / Faecal incontinence (with impaction)
  • Stercoral ulceration/perforation (rare, severe impaction)
  • Megacolon (rare)

Prevention

  • Adequate dietary fibre and fluid intake.
  • Regular physical activity.
  • Heeding the urge to defecate.
  • Judicious use of constipating medications.

Patient education

  • Explain normal bowel function variability.
  • Importance of diet (fibre), fluids, and exercise.
  • Bowel training habits.
  • Correct use of laxatives (avoiding long-term stimulant use unless necessary).
  • When to seek further medical advice (alarm features, lack of response).

Uganda-specific notes

Low fibre diet common. Emphasis on lifestyle measures crucial. Assess for common secondary causes. Availability of different laxative types may vary. Bisacodyl and Lactulose are mentioned in UCG.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 6, Section 6.4.1

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