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Probability diagnosis

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Simple constipation: low-fibre diet, poor fluid intake, lifestyle and bad habit

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Slow transit (idiopathic) constipation

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Normal transit (irritable bowel syndrome)

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Serious disorders not to be missed

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Intrinsic neoplasia: colon, rectum or anus, especially colon cancer

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Extrinsic malignancy (e.g. lymphoma, ovary)

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Hirschsprung (children)

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Pitfalls (often missed)

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Impacted faeces

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Local anal lesions (e.g. anal fissure)

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Drug/purgative abuse

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Hypokalaemia

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Depressive illness

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Acquired megacolon

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Diverticular disease

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Rarities:

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  • lead poisoning

  • hypercalcaemia

  • hyperparathyroidism

  • dolichocolon (large colon)/megarectum

  • Chagas disease

  • systemic sclerosis

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Masquerades checklist

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Depression

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Diabetes (rarely)

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Drugs (opiates, iron, others)—see list

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Thyroid disorder (hypothyroidism)

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Spinal dysfunction (severe only)

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Is the patient trying to tell me something?

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May be functional (e.g. depression, anorexia nervosa).

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Key history

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Define what exactly the patient means by constipation. The history should include stool consistency, frequency, ease of evacuation, pain on defecation and the presence of blood or mucus. A dietary and drug history is important.

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Key examination

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  • The important aspects are abdominal palpation and rectal examination

  • Test perianal sensation and the anal reflex

  • Perform sigmoidoscopy

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Key investigations

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  • Basic tests are FBE/ESR, occult blood in stool

  • Consider serum calcium, potassium, CEA and TFTs

  • If appropriate refer for sigmoidoscopy or colonoscopy and radiological studies (e.g. CT colonography, bowel transit studies)

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Diagnostic tips

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  • Alarm symptoms are rectal bleeding, recent constipation in those >40 years and family history of cancer.

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

  • Beware of hypokalaemia causing constipation in the elderly patient on diuretic treatment. Drugs selected associated with constipation: analgesics, opioids esp. codeine, TCAs, antacids esp. aluminium hydroxide, Ca channel blockers, SSRIs, cough mixtures, anti-cholinergics, benzodiazepines.

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