Constipation and

Obstipation
Group 9
(Clinical Workshop)
OGOY, Racquel S.
Olayiwola, Monsurrat Dasola
Olowokeeree, Mary Temitope
Onose, Oroide
Parawala, Burhanuddin
Ramos, Ralph Harold
Vasanrungruang, Nalinee

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OUTLINE OF THE REPORT

I. Epidemiology
II. Synopsis
III. Mechanisms of Defecation
IV. General Physical Examination
V. Hypothetical Case
a. General Survey
b. History of Present Illness
c. Physical Examinations
d. Algorithm
e. Case Diagnosis
VI. Diagnostic Examinations
VII.Evidence-Based Examination
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EPIDEMIOLOGY

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Epidemiology
a. Age-Related Demographics
Occurs in all ages (Newborns-elderly)
30-40% adults older than 65 years old
b. Sex-Related Demographics
Female to male ratio (3:1)
c. Race-Related Demographics
Higher among non-white
Less among Asians and higher among westerns
Less frequent among black Africans than white Africans

Constipation, Basson, et.al, 2014

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SYNOPSIS
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Constipation VS Obstipation

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Constipation
a common complaint in clinical practice
and usually refers to persistent, difficult
infrequent, or seemingly incomplete
defecation
Processes involved in constipation
originating from the colon or rectum
(Harrison's Principles of. Medicine)

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The Rome criteria

initially introduced in 1988

have become the research-standard definition of constipation

Medscape
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The Rome III criteria

patient must have experienced at least 2 of the
following symptoms over the preceding 3
months
Fewer than 3 bowel movements per week
Straining
Lumpy or hard stools
Sensation of anorectal obstruction
Sensation of incomplete defecation
Manual maneuvering required to defecate
Medscape
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Etiology
Acute constipation suggests an
organic cause, whereas
Chronic constipation may be organic
or functional cause

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THE MERCK. MANUAL

Example

Causes
Acute constipation*
Bowel
obstruction

1.Volvulus,
2.fecal impaction
3.hernia,
4.adhesion

Adynamic ileus

1.Peritonitis,
2.major acute illnesses (e.g sepsis)
3.head or. Spinal. Trauma

Drugs

1.Anticholinergics
(eg,
antihistamines,
antipsychotics,
antiparkinsonian drugs, antispasmodics),
2. Cations (iron, aluminum, Ca, barium, bismuth),
3.Opioids,
4.Ca channel blockers,
5. General anesthetics
Constipation shortly after start of therapy with the drug
THE MERCK. MANUAL

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Causes

Example

Chronic constipation*
Colonic tumor

Adenocarcinoma of the. Sigmoid colon

Metabolic
disorder

1.
2.
3.
4.
5.
6.
7.

Diabetes mellitus
hypothyroidism
hypocalcemia
hypercalcemia
pregnancy
uremia
porphyria

CNS Disorder

1.
2.
3.
4.

Parkinson disease,
multiple sclerosis
stroke
spinal cord lesions

PNS DIsorder

1.
2.
3.

Hirschsprung disease
neurofibromatosis
autonomic neuropathy

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THE MERCK. MANUAL

Systemic
Disorder

Functional
Disoder

Dietary factors

1.
2.
3.
4.

Systemic sclerosis
amyloidosis
dermatomyositis
myotonic dystrophy

1.
2.
3.

Slow-transit constipation
irritable bowel syndrome
pelvic floor dysfunction (functional defecatory
disorders)

1.
2.
3.

Low-fiber diet,
sugar-restricted diet,
chronic laxative abuse

THE MERCK. MANUAL

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Obstipation
sometimes called obstructive constipation
loss of ability to pass stool or gas due to
blockage or obstruction in the intestines
It is a persisting or chronic constipation that
has developed into a continuous and difficult
to control condition.
when left untreated may lead to other lifethreatening conditions (e.g. peritonitis,
strangulated bowel)
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Causes of Obstipation
Intestinal obstruction
mainly the cause of obstipation
It can be a blocked bowel (small intestine) or a
blocked colon (large intestine)
Prolonged or untreated constipation, is
caused by
1. lack of dietary fiber intake
2. decreased water intake,
3. decreased physical activity
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Causes of Obstipation
Structural causes
When the rectal wall did not develop properly
When caused by colon obstruction
Hernias
Tumors
Inflammation
Structural abnormalities in the intestines
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SIGNS AND. SYMPTOMS OF

OBSTIPATION
Abdominal symptom

Physical symptoms

Constipation
Abdominal distension
Bloating- enlargement or
feeling of fullness
Persistent cramping and pain
Borborygmi- increased bowel
sounds

Foul breath odor

Rapid pulse
(tachychardia)
Nausea and vomiting
Fever and dehydration

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Constipation vs Obstipation
difficulty in defecation wherein chronic version of constipation
an individual experience three or may develop at a longer period of
less bowel movements in one
time (over a year)
week
inability to pass stool which
easily treated and can be
means there can be no bowel
regulated
movement at all
more difficult to treat because of
its vast causes which is sometimes
born of other diseases.

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MECHANISM OF
BOWEL
MOVEMENT

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www.ihealthblogger.com/2013/04/obstipation-causessymptoms-and.html

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History Taking
1.
2.
3.
4.
5.
6.

What is the frequency of the patients bowel movement?

Does the patient usually look at the his/her stool?
What does the stool look like in terms of color and bulk?
Is the passage of the stool hard and painful?
Is there a need to strain unusually hard?
Is there a sense of incomplete defecation or pressure in the
rectum?
7. What remedies has the patients tried?
8. Do medications, stress, unrealistic ideas about normal bowel
habits or time and setting allotted for defecation play a role?
9. Is there a complete constipation with no passage of either
feces or gas, obstipation?

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Connection of Constipation with Abdominal

Distention
Chronic abuse of laxatives
Disorders of the myenteric plexus
Advanced age
Use of anticholinergic drugs
Feces- an accumulation of large amounts of
feces (i.e. Megacolon)

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Connection of Constipation with Abdominal

Distention
Most commonly associated with a history of
chronic constipation or laxative use
Plastic nature of the masses can often be
palpated through the abdominal wall and rectal
examination may show stool in the vault
Tympanites is usually absent

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Physical Examination
1. Examination Of the the Abdomen
A. Inspection
Globular
Umbilicus
Protruding
B. Palpation
Masses
C. Percussion
Tympanitic
D. Auscultation
Decreased bowel sound
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Digital Rectal Examination

Position
If standing
Rest the upper body in examining table
If Lying down
Position the patient. To his. Left side with the right Knee Flex
Inspection
Spread the buttocks
Inspect the sacrococcygeal
And periaanal area
Ask to bear down
Facilitate dilation to the anus
Inspection for mass and lesion
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 Palpation
Insert the whole digit
Feel for the consistency of the rectal wall
Thru left rotating to posterior
Then then right rotating to anterior

34
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 Once on the anterior side rectum

Palpate for the prostate gland
2 lateral lobe and
median sulcus
Note for any area of nodule
Masses
Tenderness
If positive blood in the gloves send it to
laboratory
35
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Red Flags
Distended, tympanitic abdomen
Vomiting
Blood in stool
Weight loss
Severe constipation of recent onset/worsening
in elderly patients

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LABORATORY
DIAGNOSIS

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Laboratory Diagnosis
Melanosis coli, or pigmentation of the colon mucosa,
-indicates the use of anthraquinone laxatives
Megacolon or cathartic colon may also be detected by colonic
radiographs.
Measurement of serum calcium potassium and thyroidstimulating hormone levels
Not responding to fiber alone and may be helped by a boweltraining regimen which involves taking an osmotic laxative.

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Diagnosis

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Diagnosis
Grade A1: Excellent evidence in favour of the test
based on high specificity, sensitivity, accuracy and
positive predictive values.
Grade B2: Good evidence in favour of the test with
some evidence on specificity, sensitivity, accuracy
and predictive values.
Grade B3: Fair evidence in favour of the test with
some evidence on specificity, sensitivity, accuracy
and predictive values.
Grade C: Poor evidence in favour of the test with
some evidence on specificity, sensitivity, accuracy
and predictive values.
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Abdominal radiography
Barium Enema
Defecating Proctography

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Blood test
Used to exclude an underlying organic cause
Used in cases with underlying metabolic or
pathologic processes

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Blood Tests
Complete Blood Count and Biochemical Profile
Detect serum Calcium levels
Exclude hypercalcemia and blood glucose
levels
Thyroid function tests
Exclude hypothyroidism and coelic screen
and total IgA

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Ultrasound
Safe, non-invasive and easily accessible mode
of imaging
Not currently utilized in children
Has potential role in quantifying the degree of
fecal lading megarectum
Monitoring of treatment response

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Role of Gastrointestinal
Transit Studies
Traditionally provided information about total and
segmental colonic transit time and overall
colorectal motor function

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Digital rectal test

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Colonoscopy
Most cost-effective
Provides an opportunity to biopsy mucosal
lesions
Perform polypectomy or dilate strictures

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Colonoscopy

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Flexible sigmoidoscopy

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HYPOTHETICAL
CASE
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 General data: Miss X, a 39 year old female,married, Roman

Catholic. She came to the emergency room and was first
admitted medical center last April, 2011 at around 11pm at
Region 1 General Hospital.
Informant: Patient and Husband
Reliability: 90%
Chief complaint: Difficulty in defecation
The patient is an alcoholic and diagnosed to have GERD.

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Vital Signs
Blood Pressure: 130/80 mm/Hg
Temperature: 37C
Pulse Rate:90bpm
Respiratory Rate: 20cpm
Weight: 80lbs

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Personal Data
Nutrition: low fiber diet,
No. of meals per day: twice a day
Food preferences: prefers meat
Coffee/Tea/Alcohol intake: drinks a lot of alcohol
Nutrient Supplement: none
Exercise: no exercise
Regularity of Sleep: 3hours
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Patient stated that she prefers meat to vegetables

and eats 2 times a day. She consumes more of low
fiber diet. She also said she does not take so much
water (3 glasses of water) and is fond of sleeping late
(from 4AM-7AM). She doesn't exercise and she takes
alcohol. She is also not taking any nutrient
supplements.
She also stated that she has been having back pain
and she rated pain as 6/10. Her weight decreased
from 120 lbs to 90 lbs.

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Social history

Works in brewery company.

Married with 3 children
Patient has been taking alcohol for the past
20years.
Does not eat vegetables .

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Past Medical History

Past medical history
Previous abdominal surgery
Family History
Symptoms of metabolic
hypothyroidism
diabetes mellitus
Neurologic
Parkinson disease
multiple sclerosis
spinal cord injury disorders.
Use of Prescription and nonprescription drug
anticholinergic
opioid drugs.
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Diagnosis
Constipation secondary to
Malnutrition

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Red flags

Increased white blood cell count

Anemia /decreased hemoglobin

Elevated C reactive protein or erythrocyte sedimentation rate (ESR)

Abnormal serum chemistries or abnormal thyroid function studies.

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Red flags

Acute onset of chronic constipation , particularly after age 50( be sure to

refer any patient above age 50 who has not previously had a colonoscopy
for that procedure)
Unexplained anaemia/ decreased hemoglobin
Rectal bleeding
Rectal pain, especially with defecation ( suggests an anal disorder)
Positive faecal occult blood test
Family history of bowel cancer, inflammatory bowel disease or celiac
disease
Fecal urgency, fecal or urinary incontinence and the need for manual
disimpaction
Abnormalities on physical exam( eg, masses in the abdomen, abnormal
rectal exam)

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EVIDENCEBASED
MEDICINE

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Relevance of Colonic Gas Analysis and

Transit Study in Patients With Chronic
Constipation

J Neurogastroenterol Motil. 2015 Jul 30;21(3):433-9. doi:

10.5056/jnm14109. Park SY1, Park HB1, Lee JM1, Lee HJ1, Park CH1,
Kim HS1, Choi SK1, Rew JS1.
1Department of Internal Medicine, Chonnam National University
Medical School, Gwangju, Korea
Population: 65 men with chronic constipation
Intervention: Colonic Gas Analysis
Methodology: Transit study
Conclusion: There is no significant difference
Outcome: The colon transit is a useful diagnostic tool in chronic
constipation but requires patient compliance
http://www.e-sciencecentral.org/articles/SC000007157

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Change of Fecal Flora and Effectiveness of the Probiotic Treatment in

Patients With Functional Constipation shorterm VSL#3
Kim SE1, Choi SC2, Park KS3, Park MI4, Shin JE5, Lee TH6, Jung KW 7, Koo HS8,
Myung SJ7; Constipation Research group of Korean Society of Neurogastroenterology
and Motility.
1Ewha Womans University School of Medicine, Seoul, Korea.2Wonkwang University
School of Medicine, Iksan, Jeollabuk-do, Korea.3Keimyung University School of
Medicine, Daegu, Korea.4Kosin University College of Medicine, Busan,
Korea.5Dankook University College of Medicine, Cheonan, Chungcheongnam-do,
Korea.6Soonchunhyang University College of Medicine, Seoul, Korea.7University of
Ulsan College of Medicine, Seoul, Korea.8Konyang University College of Medicine,
Daejon, Korea
Population: Thirty patient fulfilling Rome lll criteria
Intervention: Effectiveness of short-term VSL#3
Methodology: Real time polymerase chain reaction
Conclusion: VSL#3 treatment can improve can improve clinical symptomsn of FC
Outcome: Further studies are needed to investigate VSL#3s additional effects
beyond altering gut flora to alleviate constipation.
http://www.e-sciencecentral.org/articles/SC00000715
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Perforation and mortality after cleansing enema for acute

constipation are not rare but are preventable
Niv G1, Grinberg T, Dickman R, Wasserberg N, Niv Y.
1Risk Management and Quality Assurance, Beilinson Hospital and Tel Aviv University,
Tel Aviv, Israel.

Population: Adult patients with constipation

Intervention: Cleansing enema for acute constipation
Methodology: retrospective and descriptive prospective study
Conclusion: treatment of acute constipation is not without
adverse events, especially in the elderly, and should be applied
carefully
Outcome: Guidelines for the treatment of acute constipation and
for enema administration are urgently needed.
http://www.ncbi.nlm.nih.gov/pubmed/23658492
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Abdominal pain, diarrhea, constipation--which symptom is

more indispensable to have a colonoscopy
Cai J1, Yuan Z1, Zhang S1.
1Infectious Disease Division,The First Affiiated Hospital of
Chongqing Medical University Chongqing 400016, P.R. China.
Problem: 580 patient with abdominal pain
Intervention :Evaluate the value of colonoscopy
Methodology: Systemic analyzed in retrospect
Conclusion: No significant difference was found in the positive
rate
Outcome: Colonoscopy is regularly recommended for
outpatients
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4348859/

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An examination of the reliability of reported stool frequency in the

diagnosis of idiopathic constipation

Ashraf W1, Park F, Lof J, Quigley EM.

1Department of Internal Medicine, University of Nebraska
Medical Center, Omaha 68198-2000, USA.
Problem: Idiopathic constipation
Intervention: Reliability of infected stool
Methodology: transit study and anorectal manometry
Conclusion: Anorectal manometry was not helpful in
discriminating
Outcome: diagnosis of idiopathic constipation should be
supported by the use of stool diaries and a colon transit
study.
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Polyethylene Glycol for Constipation in Children

Younger Than Eighteen Months Old
1Wright State University School of Medicine and The Children's
Medical Center, Dayton, Ohio 45404, USA. sonia.michial@wright.edu
. Michail S1, Gendy E, Preud'Homme D, Mezoff A.
Population: Patient younger 18 months
Intervention: Polyethylene glycol
Methodology: Retrospective chart review
Conclusion: Oral powdered polyethylene glycol efffective for patient
younger than 18 months
Outcome: Dose and safety profiles are similar for those reported in
older children.

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