Constipation is a common gastrointestinal symptom characterized by infrequent, difficult, or incomplete evacuation of stool.
📌 Definition
- Rome IV Criteria (Functional constipation, ≥2 of the following for ≥3 months, onset ≥6 months before diagnosis):
- Straining during >25% of defecations
- Hard/lumpy stools (Bristol type 1–2) >25% of defecations
- Sensation of incomplete evacuation >25% of defecations
- Sensation of anorectal obstruction/blockage >25% of defecations
- Manual maneuvers to facilitate defecation >25% of defecations
- <3 spontaneous bowel movements/week
🔎 Etiology
1. Primary (Functional) Constipation
- Slow colonic transit
- Outlet obstruction (pelvic floor dyssynergia)
- Idiopathic
2. Secondary Constipation
- Dietary/lifestyle: Low fiber, dehydration, inactivity
- Drugs: Opioids, anticholinergics, calcium channel blockers, iron, antidepressants
- Medical conditions:
- Endocrine/metabolic: hypothyroidism, diabetes, hypercalcemia
- Neurological: Parkinson’s, multiple sclerosis, spinal cord lesions
- Structural: Colorectal cancer, strictures, rectocele
⚕️ Clinical Features
- Infrequent stools, straining, hard stools, sense of incomplete evacuation.
- Bloating, abdominal discomfort.
- Digital evacuation/manual assistance in severe cases.
- Red flag signs (suggesting organic disease):
- Onset in old age
- Rectal bleeding, anemia
- Weight loss, loss of appetite
- Family history of colorectal cancer
🧪 Diagnosis
- Clinical history and examination (including digital rectal exam).
- Basic labs: CBC, thyroid function, blood sugar, calcium if indicated.
- Colonoscopy: if alarm features, change in bowel habits, or suspicion of obstruction.
- Transit studies, anorectal manometry for refractory cases.
💊 Management
1. General Measures
- Increase dietary fiber (fruits, vegetables, whole grains).
- Adequate hydration.
- Regular physical activity.
- Bowel training: regular timing after meals.
2. Pharmacological
- Bulk-forming agents: Psyllium, methylcellulose.
- Osmotic laxatives: Lactulose, polyethylene glycol (PEG), magnesium hydroxide.
- Stimulant laxatives (short-term): Bisacodyl, senna.
- Stool softeners: Docusate sodium.
- Prokinetics/secretagogues (in refractory cases): Prucalopride, lubiprostone, linaclotide.
3. Other Measures
- Biofeedback therapy for pelvic floor dysfunction.
- Surgery (colectomy) in very rare, refractory colonic inertia.
⚠️ Complications
- Hemorrhoids
- Anal fissure
- Rectal prolapse
- Fecal impaction
- Megacolon
