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Diagnosing constipation.

Stomachache, gastric pain

Diagnosis of constipation

Although one can easily say if he is constipated or not, the key to the right diagnosis is not that easy! Its diagnosis does not only rely on a simple “rate your constipation from one to ten”, or “how many times a week do you usually defecate”. Rather, constipation is quite difficult to assess - it is complicated to assess objectively and it can be a symptom of a wide array of conditions.

The diagnosis of constipation is collectively a careful observation and interrogation into the sequence of events that made the patient conclude constipation. This includes frequency (most probably fewer than three bowel movements per week), consistency is to whether the stools are lumpy or hard, excessive effort required on straining, longer time required for defecation (or prolonged defecation), as well as the need to ask whether support for the perineum or digitating the anorectum is essential to promote defecation. In greater than 90% of cases there are no underlying conditions involved (such as cancer, hypothyroidism, or depression). In the absence of underlying conditions, the patient will usually respond promptly to simple lifestyle modification such as increasing fluid intake, exercising, and supplementing dietary fiber at approximately 15-25 grams per day. The ultimate things to note in constipation cases is the diet, history of medications (since some medications can actually cause constipation), as well as a careful inquiry into psychosocial issues to rule out depression.

Aside from history, and just like what is usually done for every complaint that merits medical attention, physical examination (and particularly a rectal examination), is very vital. A rectal examination is done through the insertion of a gloved index finger into the rectum to check for sphincter tone, smoothness of the rectal mucosa, presence of masses or hemorrhoids, and the presence or absence of fecal matter along with the examining finger. Through rectal examination, fecal impaction can be ruled out as a cause for constipation, and other diseases that may suggest disorders with evacuation (such as those associated with a high anal sphincter tone) can also be ruled out.

If symptoms such as blood from the rectum, weight loss, as well as anemia, exist along with constipation, a more thorough examination becomes mandatory. In order to exclude structural diseases such as cancer or strictures, a flexible sigmoidoscopy with barium enema, or a simple colonoscopy, is important, especially in patients that age greater than 40 years old. These modalities can be of great help in detection of troublesome constipation, which may not be alleviated by increased fluid and fiber intake alone.

Among the findings that can be detected using imaging modalities such as sigmoidoscopy or colonoscopy are the presence of lesions and strictures. A simple colonoscopy alone can provide opportunities to dilate strictures, biopsy mucosal lesions and a whole lot of other therapeutic interventions. If in case the constipation is due to use of anthraquinone laxatives, presence of pigmentation (melanosis coli) of the colon mucosa may be seen, although this can also be detected even by just a simple history-taking. Some unexpected conditions can also be revealed only through radiographs. This will include the megacolon or cathartic colon.

Excessive straining may also be a culprit for the presence of hemorrhoids, so one should be very careful to elicit information regarding straining. Any weakness also in the pelvic floor or any injury towards the pudendal nerve can be reasons for obstructed defecation which unfortunately surface only a couple of years later – thus one always has to elicit information regarding any history of trauma or surgery that may concern the perineum.

A careful history-taking and physical examination, as a rule, are very important for physicians – and the same applies to cases presenting with constipation. Who knows, these alone can save a patient from spending more money for imaging modalities, and therefore get his or her treatment, fast!

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