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Introduction

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I have finally kum to the konklusion, that a good reliable set of bowels iz wurth more tu a man, than enny quantity of brains.

Henry Shaw (1818–85), Josh Billings

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Constipation is the difficult passage of small hard stools. The Rome III criteria (refer www.romecriteria.org) define it has having two or more of the following, for at least 12 weeks:

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  • infrequent passage of stools <3/week

  • passage of lumpy or hard stools at least 25% of time

  • straining >25% of time

  • sensation of incomplete evacuation >25% of time

  • use of manual manoeuvres >25% of time

  • sensation of anorectal obstruction/blockage >25% of time

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Accordingly it affects more than 1 in 5 in the population.1

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However, the emphasis should be on the consistency of the stool rather than on the frequency of defecation; for example, a person passing a hard stool with difficulty once or twice a day is regarded as constipated, but the person who passes a soft stool comfortably every two or three days is not constipated. Various causes of chronic constipation are summarised in FIGURE 41.1.

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Key facts and checkpoints

  • The survey showed 10% of adults and 6% of children reported constipation in the preceding 2 weeks.

  • Up to 20% of British adults take regular laxatives.2

  • Constipation from infancy may be due to Hirschsprung disorder.

  • Diet is the single most important factor in preventing constipation.

  • Beware of the recent onset of constipation in the middle-aged and the elderly.

  • Bleeding suggests cancer, haemorrhoids, diverticular disorder and inflammatory bowel disease.

  • Unusually shaped stools (small pellets or ribbon-like) suggest irritable bowel syndrome.

  • Always examine the abdomen and rectum.

  • Plain abdominal X-rays are generally not useful in the diagnosis of chronic constipation.

  • The flexible sigmoidoscope is far superior to the rigid sigmoidoscope in investigation of the lower bowel.

  • Intractable constipation (obstipation) is a challenge at both ends of the age spectrum but improved agents have helped with management.

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A diagnostic approach

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Using the diagnostic strategy model (see Table 41.1), the five self-posed questions can be answered as follows.

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Table Graphic Jump Location
Table 41.1

Chronic constipation: diagnostic strategy model

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