Chapter 41

### Introduction

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

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:

• 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

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

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.

###### FIGURE 41.1

Causes of chronic constipation

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.

### A diagnostic approach

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

Table 41.1

Chronic constipation: diagnostic strategy model

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