constipation%20in%20adults%20-%20chronic%20functional
CONSTIPATION IN ADULTS - CHRONIC FUNCTIONAL
Constipation is an unsatisfactory defecation distinguished by difficult stool passage, infrequent stools or both.
Difficult stool passage may include straining, feeling of difficulty in passing stool, incomplete evacuation, lumpy/hard stools, prolonged time to defecate, need for manual maneuver to pass stool, abdominal discomfort and feeling of anorectal blockade.
Chronic constipation is considered when symptoms of constipation have existed ≥3 months.
Symptoms of chronic constipation may be due to dysfunction of intestinal motility, visceral sensitivity, anorectal musculature or the enteric nervous system.

Definition

Symptom-based Definition of Constipation

  • Unsatisfactory defecation distinguished by difficult stool passage, infrequent stools or both
  • Difficult stool passage may include:
    • Straining
    • Feeling of difficulty in passing stool
    • Incomplete evacuation
    • Lumpy/hard stools
    • Prolonged time to defecate
    • Need for manual maneuver to pass stool
    • Abdominal discomfort
    • Feeling of anorectal blockade
  • Other symptoms that may alert physician of an underlying constipation include bloating, fullness, and need for laxatives
  • Chronic constipation is considered when the above symptoms have existed for ≥3 months

Pathophysiology

  • Symptoms of chronic constipation may be due to dysfunction of intestinal motility, visceral sensitivity, anorectal musculature or the enteric nervous system
  • Functional constipation has no evidence of structural or metabolic disease to account for the symptoms  
    • Risk factors for functional constipation include increasing age, female sex, and decreased caloric intake
    • Rome IV diagnostic criteria for functional constipation include:  
      • >2 of the following:  Hard or lumpy stools >25% of bowel movements, manual maneuvers to facilitate >25% of bowel movements, sensation of incomplete evacuation >25% of bowel movements, sensation of anorectal blockage or obstruction >25% of bowel movements, straining during >25% of bowel movements, <3 spontaneous bowel movements/week
      • Loose stools are rarely seen with no laxative use
      • Insufficient criteria for irritable bowel syndrome
      • Above criteria fulfilled for the last 3 months with symptoms starting at least 6 months before diagnosis
  • Functional or primary constipation categories include normal or slow transit constipation, colonic inertia, pelvic floor dysfunction or outlet obstruction, and combination of causes, eg pelvic floor dysfunction and slow transit constipation

Signs and Symptoms

Alarm Symptoms

  • If any of the following symptoms are present, a patient should undergo further diagnostic testing
    • Weight loss >4.5 kg or >10% in 3 months
    • Loss of appetite
    • Vomiting
    • Acute onset of constipation in the elderly
    • Change in stool caliber
    • Family history of colon cancer or inflammatory bowel disease (IBD)
    • Fever
    • Abnormal physical signs (eg abdominal mass)
    • Rectal bleeding and/or prolapse
    • Hematochezia
    • Iron-deficiency anemia (IDA)
    • Positive fecal occult blood test
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