Constipation is an extraordinarily common cause of patient morbidity
in the U.S. It affects an estimated 1.7 million children and 33
million adults, accounting for more than 2.5 million physician visits
and 92,000 hospitalizations each year.1–4 The
incidence of constipation increases with age, with 30% to 40% of
persons >65 years old citing constipation as a problem.4,5 Constipation
affects as many as 80% of critically ill patients and is
directly associated with patient mortality in this population.6
Physicians and patients define constipation
differently. Physicians have traditionally defined constipation
as less than three bowel movements per week. In contrast, patients
commonly define constipation in terms such as abdominal discomfort, bloating,
straining during bowel movements, or the sensation of incomplete
evacuation. Consequently, constipation should not be defined simply
by stool frequency alone because doing so maximizes the potential
to underdiagnose a significant number of patients who suffer from
the condition.7 The Rome criteria for the definition
of constipation are listed in Table 77-1.8
77-1 Rome Criteria for Diagnosis of Constipation |Favorite Table|Download (.pdf)
77-1 Rome Criteria for Diagnosis of Constipation
|Two or more of the following must be present to make a diagnosis
|Straining at defecation at least 25% of
|Hard stools at least 25% of the time|
|Incomplete evacuation at least 25% of
|Less than three bowel movements per week|
|Chronic constipation includes symptoms for at
least 12 wk (consecutive or nonconsecutive) in the preceding 12
Constipation is a complicated condition with
multiple, often overlapping causes (Table 77-2).
Gut motility is affected by diet, activity level, anatomic lesions,
neurologic conditions, medications, toxins, hormone levels, rheumatologic
conditions, microorganisms, and psychiatric conditions. Constipation
is best thought of as either acute or chronic as doing so helps
formulate a differential diagnosis. Due to the rapidity of symptom
onset, acute constipation is intestinal obstruction until proven
otherwise. Common causes of intestinal obstruction include quickly
growing tumors, strictures, hernias, adhesions, inflammatory conditions,
and volvulus. Other causes of acute constipation include the addition
of a new medicine (e.g., narcotic analgesic, antipsychotic, anticholinergic,
antacid, antihistamine), change in exercise or diet (e.g., decrease
level of exercise, fiber intake, or fluid intake), and painful rectal
conditions (e.g., anal fissure, hemorrhoids, anorectal abscesses,
proctitis). Chronic constipation can be caused by many of the same conditions
that cause acute constipation. However, some specific causes of
chronic constipation include neurologic conditions (e.g., neuropathies,
Parkinson’s disease, cerebral palsy, paraplegia), endocrine
abnormalities (e.g., hypothyroidism, hyperparathyroidism, diabetes),
electrolyte abnormalities (e.g., hypomagnesia, hypercalcemia, hypokalemia),
rheumatologic conditions (e.g., amyloidosis, scleroderma), and toxicologic causes
(e.g., iron, lead).
77-2 Differential Diagnosis of Constipation
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