Ronald Estrada Seminario
Constipation is defined as the evacuation disorder characterized by persistent difficulty in defecation, increased consistency of stool, feeling of incomplete evacuation and / or infrequent bowel movements less than three times a week, considering that most People do at least three bowel movements weekly.
Constipation is a very frequent reason for consultation for both the clinical doctor and the specialist.
It is possible to define two modalities of constipation: the functional one (without warning signs), and the pathological one, which is related to certain pathological entities such as colon cancer, diverticular disease, degenerative diseases, etc.
In turn, functional constipation can be subdivided into two main groups: intestinal transit disorders and evacuation disorders, which frequently coexist in the same patient.
Causes of constipation
The causes of constipation are multiple and of varied etiologies, as can be seen below.
Neurological / neuropathic disorders
Endocrine / metabolic conditions
Gastrointestinal disorders and painful local conditions
Chronic functional constipation is generally due to insufficient intake of plant fiber, colonic transit disorders, or abnormal anorectal function.
Aggravating factors in this type of constipation are age, low calorie intake, prolonged fasting, female sex, and intake of antidepressants and other drugs, as detailed below.
Changes in intake, absence or decrease of physical activity, sedentary lifestyle, minimal intake of water, excessive intake of coffee and alcohol, prolonged rest, myopathies or colonic neuropathies, represent additional and aggravating causes.
In contrast, regular physical exercise promotes motility, strengthens the abdominal press, and thus ensures better bowel movement.
The medical history and physical examination should focus on identifying possible causes, symptoms, and warning signs. The history should focus on the history of the patient's evacuation rite, the use of manual maneuvers and / or changes of position during evacuation, the time of evolution, the change in shape and color of the stool, and the presence of mucus or blood during bowel movements. Likewise, it is necessary to inquire about the intake of laxatives and personal and family history of colonic pathology.
A recent onset of constipation in an individual 50 years of age or older requires that a colonic neoplasm be ruled out.
Constipation can manifest clinically through its complications: acute hemorrhoidal pathology (thrombosis) and anal fissure. The anal fissure consists of a sharp tear of the anoderm. The patient presents sudden, stabbing pain, accompanied or not by proctorrhagia.
The physical examination must be exhaustive. In addition to the general evaluation, the abdomen, pelvis, and rectum should be carefully examined for hernias, hepatosplenomegaly, or intra-abdominal masses.
The pelvic gynecological examination in women should be indicated to rule out injuries to the vaginal posterior wall, rectocele or rectal prolapse, therefore the treating physician should always consider constipation as an interdisciplinary management entity.
Although constipation is a high-frequency entity in the general and clinically diagnosed population, some patients refractory to treatment or who have a recently started change in the evacuation rhythm will require complementary studies detailed below.
Self-medication, over-the-counter medications
Laboratory: Complete blood count, Sedimentation rate (VES), Ferremia, transferrin, saturation percentage, ferritin, Proteinogram by electrophoresis, Occult blood in fecal matter, Hepatogram. Abdominal-pelvic Ultrasound: in order to rule out expansive abdominal-pelvic processes, Video colonoscopía: indicated in the presence of proctorrhagia, anemia, recent-onset constipation, abdominal pain and risk factors for colonic carcinoma: family history of colon carcinoma, ulcerative colitis, disease of Crohn's disease and familial colonic polyposis.
Colonic transit measurement: transit tests are performed with a radiopaque marker. They are carried out five days after ingesting radiopaque material and an x-ray is performed which should indicate that 80% of it has been removed from the colon.
It is useful to measure intestinal transit time.
Anorectal and pelvic floor tests: These are indicated when suspicion of functional disorders of the pelvic floor, when there are difficulties to evacuate the rectum, feeling of rectal occupation, rectal pain and the need to resort to digital maneuvers such as compression of the posterior wall of the vagina.
A simple clinical test that can be performed in the office to check the puborectal lack of relaxation is to ask the patient during digital rectal examination to exert force to expel the index finger. Backward movement of the puborectalis during exertion will indicate whether there is good coordination of the pelvic floor muscles.
Expulsion of a balloon through the rectum while sitting or in left lateral decubitus is another alternative test for the study of anorectal functionality.
Anorectal manometry identifies the presence of alterations in the tone of the anal sphincter at rest or in activity.
Defecography consists of a radiopaque enema through which lateral radiographs are obtained during expulsion of the barium. This technique allows diagnosing anatomical defects of the rectum.