The first difficulty is to be clarified this symptom, where between a part of subjectivity. Neither the size, nor the shape, nor the weight of the stools are satisfactory markers; their frequency would be a more reliable indicator (normal transit = 3 to 2L stool per week). The second difficulty is to distinguish constipation from irritable bowel syndrome (IBS), which is very frequent and benign (Table 9), from a pathological condition requiring specific management. The criteria of ROME II can be a help, but do not eliminate an organicity.
The decision to undertake additional mainly morphological examinations is dictated by the clinical context.
Warning signs : recent change or appearance of symptoms, weight loss, fever, blood in the stool, resistance to symptomatic treatment.
Risk factors :
– family history of polyp or colon cancer;
– dietary errors: insufficient intake of plant fibers, fluid intake;
– immobilization or bed rest.
Any noticeable anomaly a physical examination with a digital rectal examination.
Apart from IBS and insufficient intake of plant fibers and water, the causes of constipation are very numerous and can be seen at any age (Table 10).
We can also try to classify the etiologies by age group:
Think of looking for the anal fissure whose painful symptomatology is not always expressed. The examination of the anus is difficult and careful digital rectal examination can palpate the painful sphincteric contracture characteristic.
Neuromuscular abnormalities, digestive intrinsic or extrinsic, are the responsibility of the pediatric gastroenterologist.
In the majority of cases, constipation of the child does not warrant further examination. It is only in case of failure of symptomatic treatment, or in the presence of more general signs associated that one is led to look for endocrine or metabolic disease, a disease such as cystic fibrosis etc.
Finally, we must always think of constipation in front of an encopresis, requiring a real “reeducation” of rectal sensitivity.
In young adults:
Isolated constipation sometimes integrates into a psychopathological context. Some authors have found up to 30% history of sexual abuse in childhood in this population. Hypothyroidism should be sought systematically.
Some malabsorption may occur initially by constipation (adult celiac disease).
From 45 years old:
The possibility of carcinomatous stenosis should always be kept in mind. The increase in the number of colorectal cancers, their poor overall prognosis, justify broad indications of colonoscopy.
One must sometimes think, in front of an aggravated old constipation, a disorder of pelvic statics. A history of pelvic obstetric trauma are very important to know.
Interrogation, clinical examination and defecography make it possible to distinguish:
– the rectocele: protrusion of the rectum into the vaginal cavity (distension of the rectovaginal fascia). The patient does endovaginal maneuvers to empty the rectum;
– the internal prolapse of the rectum gives an incomplete emptying sensation and may lead the patient to perform endoanal maneuvers to evacuate;
– the descending perineum: at the pushing effort the visceral handset tilts back beneath the pubococcygeal line and the patient is obliged to exert a manual perineal pressure to go to the saddle.
In the elderly:
As with other ages of life, but with greater frequency, we must add to the other previous extracolonic causes of constipation:
– hypokalemia, hyponatremia, hypercalcemia, renal failure;
– Iatrogenic constipation justifying preventive treatment because the responsible medication can often not be removed;
– ischemic colitis that can progress to stenosis;
– diverticular colitis, extremely common at this age.
When an organic etiology seems to be reasonably discarded, the patient should be reassured explaining that constipation is always a benign symptom and not a disease.
The treatment is first of all governed by diet and diet rules : fiber-enriched diet, abundant drinks, exercise.
Then, a treatment can be proposed associating willingly several families of drugs, whose dose is individually adapted: mucilage, osmotic laxatives, lubricants, small enemas or suppositories, antispasmodics, etc.