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A 37-year-old woman comes to your clinic for "constipation," which she has had since childhood. She states that a work-up by her pediatrician turned up nothing. She reports intermittent, crampy abdominal pain that reaches 8 out of 10 in severity and is relieved "mostly" by a bowel movement. She has a bowel movement nearly every day, but her stools are usually hard. When the pain occurs, her stools are "really hard." She was recently laid off from her job and has noted an increase in her abdominal pain and hard stools.

  • Does she really have constipation?
  • What additional questions would you ask to learn more about her symptoms?
  • Do her symptoms suggest a serious disease?
  • How helpful is the history in diagnosing the etiology of constipation?

Constipation is a common digestive symptom, with a prevalence of 2% to 28%, depending on the definition used.13 The classic definition—fewer than 3 bowel movements per week—has been expanded to acknowledge patients' broader use of the term. In a survey of healthy young adults, 52% defined constipation as straining to pass fecal material, 44% thought it was the process of passing hard stools, and 34% believed it was the inability to have a bowel movement at will. Only 32% believed that constipation was the infrequent passage of stool (definitions were not mutually exclusive).4

Some patients describe themselves as constipated, even though they have one or more bowel movements a day, whereas others with fewer than 3 per week do not. Constipation leads to 2.5 million physician visits per year5 and more than $800 million in expenditures on laxatives.6 There is an increased prevalence among the elderly and female population. Other risk factors include limited physical activity, low socioeconomic status, and low caloric intake. In a national Canadian survey, 34% of persons with constipation had seen a physician for their symptoms.7

Constipation may reflect serious disease, but most people with this symptom have a benign, functional disorder. Effective history taking can help guide further evaluation. Knowing the alarm features that suggest serious causes of constipation and using a sensitive interviewing style will help you appropriately evaluate this often embarrassing symptom.

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Organic illnessAssociated with detectable structural changes in an organ.
Functional illnessThis term is being redefined but currently means there is no simple single organic explanation for a patient's symptoms.
Acute constipationSymptoms for < 3 months.
Chronic constipationSymptoms persisting > 3 months, often for many years.
Irritable bowel syndrome (IBS)A functional gastrointestinal syndrome without a single organic cause, characterized by chronic abdominal pain and bloating relieved by a bowel movement, feelings of incomplete evacuation and/or passage of mucus, change in the number of bowel movements or change in stool consistency (harder or softer), episodic diarrhea alternating with constipation, and periods of normal bowel function. Symptoms are usually exacerbated by stress.

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