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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 (1818–1885), JOSH BILLINGS
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Constipation is the difficult passage of small hard stools. The Rome III criteria 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 clinical 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 does not require any diagnosis. Various causes of chronic constipation are summarised in FIGURE 31.1.
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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.1
Up to 20% of British adults regularly take laxatives.2
Constipation from infancy may be due to Hirschsprung disorder.
Diet is the single most important factor in preventing constipation.
Beware of recent-onset constipation in the middle-aged and the elderly.
Bleeding suggests cancer, haemorrhoids, diverticular disorder and inflammatory bowel disease.
Always examine the abdomen and rectum.
Plain abdominal X-rays are generally not useful in the diagnosis of chronic constipation.
The flexible sigmoidoscope examines the lower bowel in detail.
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 31.1), the five self-posed questions can be answered as follows.
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